Failure to Provide Timely Skin and Incontinence Care
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with impaired skin integrity and incontinence. Despite a care plan and physician's orders indicating the need for weekly skin assessments and regular check and change assistance for incontinence, staff did not identify or document multiple areas of skin breakdown on the resident's toes and feet. Observations confirmed the presence of purple and red abrasion-type wounds with open areas on both feet, which were not recorded in the weekly skin assessments, treatment administration record, or physician's orders. The facility's policy required full assessment and documentation of skin breakdown, but this was not followed for the resident in question. Additionally, the facility did not provide a policy on the process or frequency of incontinence care for residents requiring check and change. Documentation showed that the resident often received incontinence care only once or twice in a 24-hour period, with only one day where care was provided four times. The resident reported long intervals between changes, sometimes remaining wet for extended periods, which required full bed changes. The lack of routine incontinence care and failure to monitor and treat skin issues in a timely manner contributed to the deficiency.