Failure to Report and Document Resident Injury
Penalty
Summary
A deficiency occurred when a resident with diagnoses including sepsis, Parkinson's Disease, schizophrenia, and dementia, who lacked capacity to make decisions, developed a red circular wound between the first and second fingers of the left hand. During observation and interview, a CNA reported the wound was likely due to the resident banging his hands and stated she had reported the wound to an LVN, who advised leaving it open to air. The resident's care plan required that skin conditions be reported to the physician and responsible party. Despite this, there was no documentation in the medical record regarding the wound, no physician's orders for treatment, and no evidence that the resident's responsible party or physician had been notified. The wound was observed on two consecutive days, and staff confirmed that no formal reporting or documentation had occurred, constituting a failure to provide appropriate treatment and care according to orders and the resident's care plan.