Failure to Complete Weekly Skin Assessments and Implement Wound Healing Supplements
Penalty
Summary
The facility failed to consistently perform weekly skin assessments and did not implement recommended nutritional supplements for wound healing for a resident with a pressure ulcer. According to facility policy, weekly Total Body Skin Evaluations were required, but documentation showed that these assessments were not completed weekly for the resident. There was a gap of over four weeks between assessments, during which time a Stage 3 pressure ulcer developed. Staff interviews confirmed that the required weekly assessments were not being performed as expected, and that earlier detection of skin issues could have potentially prevented the development of the pressure ulcer. Additionally, the facility did not follow through on a wound care nurse practitioner's recommendation to provide a specific nutritional supplement, Arginaid, to promote wound healing. Although the recommendation was communicated to the facility's registered dietician and noted in the resident's record, there was no evidence that the supplement was ordered or administered as intended. Staff interviews revealed confusion regarding the administration of the supplement due to the resident's need for honey thick fluids, and no documentation was found to confirm that the supplement was provided as recommended.