Failure to Assess and Document Open Skin Area
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services for a resident with an open skin area. The resident, who had diagnoses including diabetes mellitus and depression, was identified as having a boil on the buttock that was open and draining. Although initial documentation included a description and measurement of the area, subsequent assessments and measurements were not completed or documented after the initial event. The clinical record lacked ongoing assessments of the open area, and there was no documentation explaining the discontinuation of prescribed mupirocin ointment. Additionally, the care plan required recording the location, size, and characteristics of the boil, but this was not consistently done. Staff interviews revealed that the resident sometimes refused observation, but at times allowed the area to be checked. The ADON stated that only certain types of wounds were routinely measured and documented, and considered the boil to be similar to a skin tear, which was only visually observed without documentation. The facility's wound management policy required the wound team to assess all new or open wounds, but this was not followed for the resident's boil. As a result, there was a lack of ongoing assessment and documentation for the resident's open skin area.