Failure to Assess and Intervene for Resident Injuries and Skin Conditions
Penalty
Summary
The facility failed to complete timely assessments and provide appropriate interventions for three residents following incidents that required nursing attention. One resident, with a history of heart failure, renal insufficiency, diabetes, and limited mobility, sustained a puncture wound to the right lower calf from a broken wheelchair. Despite the resident and a CNA reporting the injury, no nursing assessment was performed for over 12 hours, and the wound was not addressed until the following day. The nurse and ADON were unaware of the injury, and the maintenance department was not notified until after the surveyor's inquiry. The care plan required staff to monitor skin and report issues, but this was not followed, resulting in delayed wound care and equipment repair. Another resident, who was severely cognitively impaired and at risk due to visual impairment and confusion, spilled hot coffee on her chest. Although the incident was reported and the physician was notified, there was no documented evidence of ongoing nursing assessment or monitoring of the affected skin area as required by the facility's process. The only documentation available was the initial incident report, and the facility acknowledged that if further assessments were completed, they were not documented. The facility also lacked policies for resident assessments or nursing documentation. A third resident, with a history of diabetes and previous skin cancer, reported a recurring sore on the top of the head. The care plan did not address this chronic skin issue, and there was no documentation of skin assessments or incident reports related to the sore. Although the resident and staff reported the issue to physicians and nurses, and treatments were attempted, there was no referral to dermatology or consistent documentation of the condition until after the surveyor's inquiry. The facility also lacked a policy for change in condition, contributing to the lack of timely assessment and intervention.