Failure to Timely Identify and Treat Resident's Open Heel Wound
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, and total dependence for mobility and personal care developed an open area on the right inner heel that was not identified or treated in a timely manner. The resident's care plan included risk factors for skin breakdown and interventions such as regular Braden scoring and assistance with turning and repositioning, but did not specify weekly skin assessments or prompt reporting of skin abnormalities to a physician. Physician orders required weekly skin assessments, but documentation of these assessments was missing, despite the Treatment Administration Record indicating they were completed. Direct observation revealed the open area on the resident's right inner foot, which had a dark reddish-brown wound bed and clear tissue covering it. The CNA providing care was aware of the wound but did not report it, assuming nurses already knew. The LPN who observed the wound did not notify the assigned nurse. Further interviews with nursing staff and the DON confirmed that the assigned nurse and DON were unaware of the wound, and no one had communicated its presence. The wound was later assessed by the wound nurse practitioner, who described it as an abrasion with granulation tissue and mild maceration, and a treatment was subsequently initiated. Review of the resident's medical record, progress notes, and shower sheets showed no documentation of the wound or evidence that the required weekly skin assessments were performed. The facility's skin care policy required daily visualization of residents' skin and risk assessment using the Braden Scale, but these procedures were not followed for this resident, resulting in a failure to identify and treat the wound in a timely manner.