Failure to Assess and Treat Skin Integrity Concerns
Penalty
Summary
The facility failed to comprehensively assess and provide appropriate treatment for a resident with multiple skin integrity concerns. The resident, who had a history of cardiac arrhythmia, heart failure, reduced mobility, and was dependent on staff for most activities of daily living, experienced several skin tears and the development of calluses on both heels. Documentation showed that a skin tear to the left arm was promptly treated and recorded, but a skin tear to the right arm was not identified, assessed, or treated according to physician orders until several days after it was first observed. Progress notes and observations indicated that a dressing was present on the right arm before an official order was entered, and there was no evidence of a skin assessment or documentation for this injury until later. Additionally, the resident developed callused areas on both heels, which were observed to be painful and, in one case, starting to flake. These areas were not documented or assessed in the medical record, and staff interviews revealed that calluses were not routinely monitored or recorded. The resident and family expressed concerns about the frequency of skin tears and the lack of aggressive treatment for the heel calluses. The wound nurse and visiting wound NP were eventually involved, and orders for skin prep were updated, but there was no initial comprehensive assessment or documentation of these areas. Facility policy required the use of professional standards of practice for skin integrity issues, including obtaining physician orders and reviewing care plans, but did not specify documentation requirements for wound assessments. The lack of timely assessment, documentation, and treatment for the right arm skin tear and bilateral heel calluses constituted a failure to provide care and treatment according to physician orders and the resident's needs.