Failure to Complete Weekly Skin Assessments and Document Oxygen Therapy Administration
Penalty
Summary
Nursing staff failed to complete weekly skin assessments and provide timely intervention for a resident who exhibited a change in skin condition. The resident, who had multiple diagnoses including heart failure, stroke, chronic lung disease, and dementia, was care planned for impaired skin integrity and required weekly skin observations and specific wound care treatments. Despite these orders, documentation showed that the last weekly wound observation was completed several weeks prior to the survey, and there was a lack of documentation regarding open wound areas in the progress notes during a period when the resident developed excoriation and open areas on the buttocks. Staff interviews and observations confirmed that the resident had open wounds that were not promptly assessed or documented, and the DON was unaware of the open areas until prompted by the surveyor. Additionally, the facility failed to document the administration of oxygen therapy when the resident's oxygen saturation dropped below the physician-ordered parameters. The resident had orders for oxygen to be applied as needed to maintain saturation above 90%, but multiple recorded pulse oximetry readings showed levels below this threshold without corresponding documentation that oxygen was administered. Observations and interviews revealed that the resident often removed the oxygen, but there was no documentation of refusals or staff interventions in the medical record as required by facility policy. The facility's policies required weekly skin evaluations and documentation of any abnormalities, as well as notification and documentation of significant changes in condition. However, the records lacked evidence of consistent skin assessments, timely wound care interventions, and appropriate documentation of oxygen therapy administration or refusals. These failures resulted in a lack of timely response to changes in the resident's condition and incomplete records regarding the care provided.