Failure to Assess and Report Resident's Ongoing Skin Condition and Symptoms
Penalty
Summary
The facility failed to adequately assess and report a resident's ongoing skin condition and associated symptoms to the physician, despite repeated complaints and documented observations. The resident, who had a history of Type 2 diabetes, neuralgia, neuritis, and obesity, was admitted with chronic vaginal yeast infection and required substantial assistance with mobility and hygiene. Care plans directed staff to monitor and report complaints of pain, itching, and skin changes, and physician orders included a gynecological consult for the chronic infection. Over several months, the resident repeatedly complained of vaginal and buttock itching and discomfort, with documented episodes of redness and flaky skin. Despite these ongoing symptoms and the care plan's instructions, the resident was not scheduled for the gynecological consultation as ordered. Observations revealed the resident experiencing significant discomfort, using her hands to scratch, and reporting that topical medication provided only temporary relief. The resident also reported that the itching affected her sleep and caused anxiety. Interviews with staff indicated that CNAs reported the resident's complaints to the charge nurse, but the treatment nurse was not informed of new symptoms, and the director of nursing confirmed that no new orders were obtained for some episodes. The treatment nurse only assessed the resident when issues were reported, and the LVN relied on CNAs to communicate changes. The facility's policy required high-quality care and prompt reporting of changes, but this was not consistently followed, resulting in unrelieved symptoms for the resident.