Failure to Assess, Monitor, and Notify Physician of Non-Pressure Skin Condition
Penalty
Summary
The facility failed to properly assess, monitor, and notify the physician regarding a non-pressure related skin condition for a resident with a history of stroke, anxiety, and depression, who required substantial to maximal assistance with most activities of daily living. Upon identification of boils and a blister during a skin assessment, staff documented the findings but did not initiate any treatment, complete an incident report, or notify the physician as required by facility policy. The electronic Medication Administration Record (eMAR) showed no treatments in place for the skin issues, and there was no documentation in the progress notes about physician notification or a treatment plan. Multiple staff interviews revealed that nurses and CNAs observed the resident's worsening skin condition, including boils and a popped blister, but assumed that appropriate reporting and documentation had already been completed by others. Staff failed to follow the facility's protocol for new skin issues, which included completing incident reports, notifying the physician and administration, and documenting the findings. The Infection Preventionist and other nursing staff were not aware of the full extent of the resident's skin issues until the condition had significantly worsened. The resident's condition deteriorated, resulting in increased pain, inability to sit, and the presence of blood and drainage from the affected areas. Eventually, the resident was sent to the hospital, where they were diagnosed with scrotal cellulitis and abscesses caused by MRSA. The lack of timely assessment, documentation, and physician notification contributed to the escalation of the resident's skin condition.