Failure to Document and Timely Intervene in Wound Care and Skin Integrity
Penalty
Summary
The facility failed to provide and document appropriate wound care and prevention measures for two residents with significant skin integrity issues. For one resident admitted with a stage 4 pressure ulcer of the sacral region and severe cognitive impairment, physician orders directed daily wound care using normal saline, medical-grade honey, and foam dressing. However, there was no documentation in the Treatment Administration Record (TAR) indicating that these treatments were provided on specific dates as ordered. Another resident, also with severe cognitive impairment and dependent on staff for hygiene, was admitted with moisture-associated skin damage (MASD) to the sacral region and buttocks. Upon admission, the initial nursing assessment identified MASD but did not document wound measurements or type, failing to establish a baseline for monitoring. Additionally, although MASD was identified on admission, a physician order for barrier cream was not obtained until three days later, delaying appropriate intervention. Interviews with nursing staff and the Director of Nursing confirmed that wound measurements should have been documented upon admission and that barrier cream should have been ordered and applied immediately when MASD was identified. The facility's own policy requires timely assessment, documentation, and intervention for skin injuries, as well as documentation of treatments as they are administered. These requirements were not met for the two residents in question.
Plan Of Correction
Corrective Action Resident 1: was discharged on 12/3/2024. Resident 2: returned from the hospital on 4/29/25. Treatments are in place for all skin conditions. Identification of Others at Risk All residents of this facility that have skin conditions have the potential to be affected by this deficiency. The Medical Records Director has reviewed the TARs for the month of May. 16 active residents with skin conditions were identified. Treatment orders were documented, no further follow-up needed. The DON has reviewed the TARs for the month of May and compared skin conditions identified upon admission against the TAR for 8 active residents. Skin conditions identified upon admission had treatment orders in place. No further follow-up was needed. The DON has inserviced the licensed nurses and the Skin IDT Committee members between 5/16/25 and 5/20/25 on the facility policy Skin And Wound Monitoring and Management, including identifying and documenting skin conditions upon admission and starting those treatments timely, and the need to document skin treatments when provided on the TAR. The Medical Records Director will review the TARs daily (M-F) for 30 days for completion. Results will be forwarded to the DON for needed follow-up. The DON/Designee will review daily (M-F) newly admitted residents to ensure that identified skin conditions have treatment orders in place. Monitoring Process The DON will provide results of the daily skin reviews to the QA&A committee during the monthly meeting for 3 months. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting for 3 months. Complete Date: 5/20/2025 The DON has inserviced the licensed nurses and the Skin IDT Committee members between 5/16/25 and 5/20/25 on the facility policy Skin And Wound Monitoring and Management, including identifying and documenting skin conditions upon admission and starting those treatments timely, and the need to document skin treatments when provided on the TAR. The Medical Records Director will review the TARs daily (M-F) for 30 days for completion. Results will be forwarded to the DON for needed follow-up. The DON/Designee will review daily (M-F) newly admitted residents to ensure that identified skin conditions have treatment orders in place. Monitoring Process The DON will provide results of the daily skin reviews to the QA&A committee during the monthly meeting for 3 months. The Quality Assessment & Assurance and Continuous Quality Improvement Committee will monitor compliance by review of findings and actions/resolutions taken during the monthly meeting for 3 months. Complete Date: 5/20/2025