Failure to Implement Care Plan for Daily Skin and Foot Assessments
Penalty
Summary
Facility staff failed to implement care plan interventions for a resident with diabetes mellitus and end stage renal disease, specifically neglecting daily skin and foot assessments as required by the resident's care plan. The care plan included interventions to check the resident's body for skin breaks and to inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. Despite these directives, staff did not identify or document developing wounds on the resident's right foot. The wounds were first discovered and treated at an outside dialysis center, where significant skin breakdown and discoloration were noted, and the facility was notified of the findings. Upon the resident's return from dialysis, facility staff completed a weekly skin assessment but failed to document the wounds or the dressing applied by the dialysis center. The LPN responsible for the assessment could not confirm whether the skin check was actually performed. The wound care physician and wound care nurse were not consulted or made aware of the wounds until several days later, and the wounds remained untreated by facility staff for five days after being discovered by the dialysis center. Interviews with facility leadership confirmed that staff did not follow the care plan or respond appropriately to the external notification of the resident's condition.