Failure to Assess, Monitor, and Document Wound Care After Resident Fall
Penalty
Summary
A resident with multiple complex medical diagnoses, including dysphagia, malignant neoplasm of the lung, and hemiplegia, experienced several falls during their stay. Following a fall, the resident sustained a laceration on the left lower leg. The nurse practitioner assessed the wound and ordered it to be left open to air and monitored for bleeding, given the resident's use of a blood thinner (Apixaban), which increased the risk of bleeding. Despite these orders, there was no documentation in the Treatment Administration Record (TAR) of any assessment, monitoring, or specific treatment orders for the left lower leg wound. Additionally, no care plan was established to address the wound or its monitoring needs. Nursing progress notes indicated that the resident aggravated the left lower leg wound by rubbing at night, and a dressing was applied to prevent further injury. However, the TAR did not reflect any daily or frequent monitoring of the wound as recommended. Subsequent nursing notes referenced the application of a xeroform dressing but lacked detailed documentation regarding the wound's characteristics, such as size, depth, or presence of swelling, discoloration, or discharge. There was also a lack of consistent and thorough documentation of the wound's status and any changes over time. Upon discharge, the post-discharge summary failed to document the resident's skin condition at the time of discharge and did not provide clear instructions for ongoing wound care. The facility's own skin management policy requires identification, evaluation, and appropriate treatment of wounds, as well as ongoing monitoring and documentation, none of which were consistently followed in this case. The lack of proper assessment, monitoring, documentation, and care planning for the resident's wound constituted a failure to provide appropriate treatment and care according to orders and the resident's needs.