Failure to Monitor Heart Failure and Document Skin Wound Assessment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs for two residents. For one resident with a known history of heart failure and peripheral vascular disease, the discharging hospital physician had directed staff to monitor for signs of heart failure daily, including assessments of lung sounds, peripheral edema, and oxygen saturations at rest and with activity. However, the resident’s electronic medical record lacked any documentation or orders for these assessments, and there was no evidence that staff routinely monitored or documented lung sounds or edema. Oxygen saturations were checked daily, but it was not specified whether these were measured at rest or with activity. Interviews with nursing staff and the assistant director of nursing confirmed that the required monitoring and documentation were not in place, despite the hospital’s explicit instructions. For another resident with multiple comorbidities including heart failure, liver cirrhosis, and polyneuropathy, the facility failed to comprehensively assess and document a non-pressure skin condition on the right great toe. Although the care plan and skin risk assessments required regular skin checks and documentation of any new wounds, the records did not include a description or measurements of the wound when it was first identified. Progress notes referenced a sore and dressing changes, but lacked detailed physical descriptions or measurements. The wound was not entered into the facility’s wound management system as required by policy, and there was no consistent tracking or documentation of the wound’s status over time. Interviews with nursing staff, the assistant director of nursing, and the nurse practitioner revealed that the wound was not properly documented or tracked according to facility policy. The facility’s skin integrity policy required that new wounds be documented in the wound management area with specific details, but this was not done. As a result, the wound’s progression could not be adequately monitored, and there was insufficient information to ensure timely and appropriate interventions.