Failure to Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to assess, monitor, and document skin wounds or growths for two residents who were reviewed for non-pressure skin conditions. This deficiency was identified through observation, interview, and record review. The facility did not ensure that care and treatment for these residents were provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, as required by regulations. The lack of assessment, monitoring, and documentation specifically pertained to non-pressure skin conditions for the two residents involved.
Plan Of Correction
1.) Residents #66 & #57 were reassessed, and no acute changes were noted. All residents have the potential to be affected. 2.) A one-time skin sweep was completed to ensure that all impaired skin integrity had treatments or were identified in other parts of the medical record as needed. 3.) Licensed nursing staff were re-educated on skin assessment, documentation, and treatment orders with impaired skin integrity. System change: The nurse managers will review skin assessments and 24-hour summary on the next business day to ensure the MD/provider was notified of impaired skin integrity. 4.) DON/Designee will review 5 medical records weekly x 12 to ensure that residents with impaired skin integrity had documentation and an order for treatment. Any non-adherence will result in 1:1 education. All audits will be reviewed by the QA committee. 5.) DON is responsible for ongoing compliance.