Failure to Observe and Report Resident Wounds During Routine Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with significant cognitive impairment and multiple diagnoses, including dementia, muscle weakness, and a seizure disorder. The resident was assessed as unable to complete the Brief Interview for Mental Status (BIMS) and required substantial to maximal assistance with activities of daily living (ADLs) such as bathing, dressing, and personal hygiene. The resident's care plan required daily skin observation during ADL care and reporting of any abnormalities, and weekly skin checks were ordered to be completed with showers. However, documentation revealed that the skin observation tool was not completed at all during March, and weekly skin checks were not properly documented. Progress notes did not indicate that wounds on the resident's ankles were identified or reported between 5/19/25 and 5/23/25. A wound was only discovered after the resident's daughter informed nursing staff of wounds on the resident's right outer ankle and left leg, which were found to be old, dry, and scabbed. The nurse agreed with the daughter that the wounds were not new. Later, a new skin tear was discovered by a nurse during scheduled wound care, with evidence suggesting it was caused by wheelchair foot pedals. The resident was unable to explain how the injury occurred. Facility leadership confirmed that the wounds should have been observed during routine care and that it was inappropriate for family members to be the first to notice the wounds.