Failure to Provide Timely Care and Treatment for Skin Tear
Penalty
Summary
A resident with a history of impaired skin integrity, including a tendency to bruise easily and use of anticoagulant medication, sustained a skin tear on the right wrist after a blood pressure cuff was applied. The resident was observed with a wound dressing on the wrist and reported the injury during an interview. Review of the resident's care plan indicated that staff were to check skin during daily care and notify the physician of abnormal findings. However, there was no documented evidence that the skin tear was identified, monitored, or addressed for care and treatment in the resident's medical record. Further review and interviews with facility staff, including an LVN and the DON, confirmed that there were no change in condition notes, physician's orders, or care plan updates related to the skin tear. The facility's wound care policy required a physician's order for wound care procedures, but this was not obtained. The lack of documentation and physician notification resulted in the skin tear not being properly assessed or treated according to facility policy and the resident's care plan.