Failure to Assess and Treat Skin Tear per Physician Orders
Penalty
Summary
The facility failed to properly assess, monitor, and treat a skin tear for one resident with severely impaired cognition and multiple diagnoses, including dementia and altered mental status. The resident was observed with an adhesive foam bandage on the right forearm that showed visible drainage, but there was no documentation of a physician's order for the dressing. The clinical record indicated that the skin tear was initially left open to air, and there was no clear documentation or communication regarding the application of the dressing. Nursing staff, including the assigned LPN and the unit manager, were unaware of any orders for wound care or who had applied the dressing. The dressing remained unchanged with visible drainage for at least a day, and the resident was unable to explain the presence of the bandage due to cognitive impairment. Facility policy required that wound treatments be provided according to physician orders, and in the absence of such orders, the licensed nurse was to notify the physician to obtain appropriate treatment directives. Despite this, no physician order was obtained for the dressing or wound care, and there was a lack of communication among staff regarding the resident's skin tear and its management. The failure to follow policy and ensure proper assessment and treatment led to the deficiency identified during the survey.