Failure to Monitor and Document Worsening Skin Conditions and New Wounds
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring of a resident's skin condition, resulting in a lack of identification and timely intervention for new or worsening skin impairments. Upon admission, the resident had multiple risk factors and existing skin issues, including rashes and fungal infections on the hands and neck, and was identified as being at risk for skin impairment. Physician orders and facility policy required regular skin assessments, documentation, and prompt notification of changes to the physician and family. However, observations revealed that the resident had visible worsening of skin conditions, including reddened, swollen, and thickened fingers, dirty nails, and rashes on multiple areas, which were not documented or communicated as required. During care, staff observed an open wound in the perianal area, which had not been previously identified or reported to the wound care nurse or documented in the resident's records. The wound care nurse and other staff were unaware of the new wound and the worsening of the resident's skin conditions. Additionally, there was no weekly documentation in the progress notes regarding the resident's rashes and fungal infections, despite these being present since admission. The wound care nurse also failed to update the resident's wound/skin care plan in a timely manner, as required by facility policy. Interviews with staff indicated a lack of awareness and communication regarding the resident's skin status, with responsibilities for assessment and documentation not being consistently followed. The facility's own policies outlined the need for regular assessment, documentation, and prompt notification of changes, but these were not adhered to, resulting in missed identification and treatment of new and worsening skin issues for the resident.