Failure to Identify and Treat Wounds Resulting in Severe Excoriation and Pain
Penalty
Summary
A resident with a history of cerebral infarction, dysphagia, dementia, major depressive disorder, anxiety disorder, trigeminal neuralgia, and morbid obesity was admitted with significant ADL deficits and was always incontinent of bowel and bladder. The care plan included interventions for skin integrity, such as frequent skin assessments, use of a pressure redistribution mattress, regular turning and repositioning, and application of barrier creams after each episode of incontinence. Physician orders specified weekly skin checks and daily application of barrier cream for incontinence dermatitis, with additional instructions for cleansing and protecting the peri-area and buttocks. Despite these orders and care plan interventions, staff failed to consistently identify and treat the resident's developing wounds. Observations revealed that during incontinent care, the resident's buttocks were severely reddened with open sores and bleeding, and no moisture barrier cream was applied. Certified Nursing Assistants (CNAs) did not report the worsening skin condition to the nursing staff, and the wound nurse was unaware of the resident's excoriated and bleeding wounds until informed by surveyors. Documentation showed that previous wounds had been marked as healed, and there were no ongoing wound notes or timely reassessments after the discontinuation of wound management specialist services. Interviews with staff confirmed that the expected protocol was not followed: CNAs were supposed to report changes in skin condition and apply barrier cream, but this was not done. The wound nurse and DON both stated they were not made aware of the resident's deteriorating skin condition until after the surveyor's observation. The lack of communication and failure to follow established wound care protocols resulted in the resident experiencing severe excoriation, open wounds, and pain.