Failure to Provide and Document Ordered Wound Care and Weekly Skin Checks
Penalty
Summary
The facility failed to provide wound and skin treatments as ordered and did not consistently perform or document weekly skin checks for multiple residents. Four out of five residents reviewed for improper nursing care were affected. For example, one resident with skin infections, morbid obesity, and congestive heart failure reported receiving leg wound care only one to two times per week, despite orders for more frequent treatments. Treatment Administration Records (TARs) for this resident showed missed documentation of both wound care and weekly skin checks on several ordered dates. Another resident with non-pressure wounds to the right upper buttock and left lower leg stated that wound care was only provided once a week during physician rounds, even though daily and three-times-weekly treatments were ordered. Documentation for this resident also showed missed skin checks and wound treatments on multiple dates. Additional residents had orders for protective skin preparations to be applied to their heels twice daily, but the TARs indicated numerous missed or undocumented applications and weekly skin checks. Staff interviews confirmed that the purpose of weekly skin checks is to identify skin concerns early and that wound care is essential for healing and infection prevention. The facility's own policy required weekly general skin checks with documentation in the medical record, but records showed this was not consistently done. The findings demonstrate a pattern of missed or undocumented wound care and skin checks, contrary to physician orders and facility policy.