Failure to Assess and Treat Resident's Skin Condition Promptly
Penalty
Summary
A resident with severe cognitive impairment, dependent on care and mobility, and diagnosed with Alzheimer's disease and dementia, developed a scabbed area on the top of her right hand. The wound was first noted in a progress note, which described pus oozing from the scab when touched, and the area was cleansed and bandaged. However, there was no immediate physician order for wound treatment, and the care plan did not include a resident-specific treatment plan for the injury. The wound was not assessed or documented according to facility policy, and the dressing applied was not dated initially. The Assistant Director of Nursing, who is responsible for wound care, was not notified of the wound until several days after its discovery, and no skin event was created as required by policy. The Director of Nursing confirmed that the origin and timing of the wound were unknown, and the wound nurse was unaware of the incident until after the survey began. The facility's policy requires prompt assessment, documentation, and notification of skin impairments, but these steps were not followed, resulting in a delay in assessment and treatment of the resident's wound.