Failure to Monitor and Intervene for Skin Integrity, Constipation, and Heel Protection
Penalty
Summary
The facility failed to provide appropriate monitoring and timely intervention for a resident with cellulitis, resulting in actual harm. The resident, who had a history of right tibia fracture, atrial fibrillation, COPD, and cellulitis, developed new redness and pain in the right lower leg. Although a nurse practitioner assessed the resident and ordered antibiotics with instructions for close monitoring and physician notification if the condition worsened, there was no documented evidence that the resident's skin condition was monitored or that the physician was notified of the decline. The resident's family member discovered the worsening condition, which had spread up the leg and onto the buttocks, and requested hospital transfer, where the resident was admitted and treated with IV antibiotics. Additionally, the facility failed to implement interventions for constipation for another resident who had a physician's order for lactulose as needed and a care plan indicating risk for constipation. Despite documentation showing no bowel movements for several days, there was no evidence that the ordered medication was administered or that the bowel protocol was initiated, as required by facility policy. The administrator confirmed the lack of intervention during this period. A third resident, who had orders for heel protection devices (Prevalon boots) while in bed due to risk factors such as atherosclerosis, end stage renal disease, and diabetes, was not provided with these devices. Multiple observations and interviews confirmed that the resident never received the ordered heel protectors since admission, despite being willing to use them. These failures affected three residents and were identified through medical record review, staff and resident interviews, and direct observation.