Failure to Assess and Monitor Skin Integrity in Resident with Breast Cancer
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive skin assessment and ongoing monitoring for a resident with a known diagnosis of invasive ductal carcinoma of the right breast. Upon admission from the hospital, the resident's discharge summary and care plan identified breast cancer and associated pain, but the initial skin evaluation and risk audit did not document any impairments or specific observations of the right breast. Despite the resident experiencing significant pain and visible changes to the breast, including redness and tenderness, there was no comprehensive assessment or documentation of the breast's condition in the medical record. Throughout the resident's stay, multiple progress notes indicated ongoing and severe pain in the right breast, with repeated requests for pain medication. However, there were no detailed assessments or updates regarding the breast's appearance or any changes in its condition. Nursing staff interviews revealed a lack of awareness about the breast cancer diagnosis and an absence of treatment orders or monitoring instructions for the affected area. The care plan interventions focused on general skin integrity and comfort but did not address the specific needs related to the breast cancer site. The situation escalated when the resident's pain became unmanageable, leading to a transfer to the emergency department, where an abscess requiring surgical intervention was identified. The facility's documentation lacked admission photos and failed to provide a baseline or ongoing assessment of the breast cancer site. The director of nursing acknowledged that the admission and skin assessments did not reflect the condition of the right breast, despite being aware of the cancer diagnosis. Facility policies required care plans to address identified problem areas and risk factors, but these were not implemented for the resident's breast cancer site.