Failure to Develop and Document Comprehensive Skin Breakdown Prevention Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address and prevent skin breakdown for a resident with multiple risk factors, including diabetes, dementia, anemia, end stage renal disease, sacral pressure ulcer, and dependence on renal dialysis. Upon readmission from the hospital, the resident was not provided with a thorough skin assessment to document the size and appearance of existing wounds or dressings. The initial care plan did not include specific interventions to prevent further skin breakdown, and updates to the care plan were not documented until much later. Observations and interviews revealed that the wound nurse and LPNs were unclear about the presence and documentation of wounds on the resident's legs upon readmission. The wound nurse stated that she was not present at the time of readmission and relied on the admitting nurse's assessment, which only noted scars and not open wounds. There was no documentation or photographic evidence of the resident's skin condition at the time of readmission, and the use or frequency of preventive interventions such as heel protectors was not recorded. The treatment administration record did not show any treatments for the resident's legs on the day of readmission. Facility policies required comprehensive skin assessments and person-centered care planning, but these were not followed. The lack of clear documentation and timely assessment led to uncertainty about the resident's skin status and the interventions in place to prevent further breakdown. The wound doctor later confirmed the presence of pressure ulcers on both lower legs, distinguishing between scars and scabs, and noted that a pressure ulcer can develop in a short period. The failure to follow policy and document interventions affected the resident's care and did not meet regulatory requirements for comprehensive care planning.