Failure to Provide Timely and Appropriate Skin and Edema Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for four residents, as evidenced by multiple instances of inadequate assessment, monitoring, and documentation. One resident exhibited signs of cellulitis on the left leg, including redness, pitting edema, and open blisters, but there was no evidence of ongoing monitoring or provider assessment for nearly two weeks after the initial findings. Nursing notes and wound care documentation did not reflect the change in condition, and there was no order for periodic skin checks during this period. The resident was not evaluated by a provider until much later, at which point cellulitis was diagnosed and treated. Another resident was observed with severely edematous legs and reported that the facility was not providing any treatment for the condition. There were no interventions for edema or cellulitis documented in the resident's care plan, medication administration record, or treatment administration record. Nursing staff confirmed that there should have been an assessment and plan in place for these issues, but none was found. A third resident had dry, scaly, and peeling feet observed on multiple occasions, but there were no treatments ordered or documented for foot care, and the care plan did not address this issue. Although a podiatry consultation was ordered as needed, there was no documentation of any podiatry visits. Additionally, the facility failed to administer ace wraps as ordered for another resident. These deficiencies demonstrate a lack of adherence to facility policies and professional standards regarding assessment, care planning, and treatment for residents with skin and edema-related conditions.