Deficiencies in Skin Assessment, Documentation, and Wound Care
Summary
A deficiency was identified regarding the lack of proper skin assessment and documentation for a resident with a significant skin abnormality. Upon observation, a resident was found to have a cutaneous horn on the scalp, as well as similar protrusions on the hand and forearm. Despite the presence of this lesion, there was no documentation of the skin protrusion in the resident's admission assessment, progress notes, or by any nursing or medical staff. Interviews with nursing staff and the DON revealed uncertainty about whether the lesion was present at admission, and the attending physician confirmed the presence of a cutaneous horn but stated it was not something he would typically document. Hospital discharge paperwork did note the lesion, but this information was not incorporated into the facility's clinical record or baseline assessment. Another deficiency was noted in the management of a wound for a different resident. The resident was observed with an adhesive foam bandage on the right forearm, which showed signs of drainage and was undated. Review of the clinical record indicated the wound resulted from a fall, but there was no physician order for the dressing or wound care. The dressing was changed by a unit manager, who admitted to not dating the initial dressing due to lack of a marker and was unable to confirm how old the previous dressing was. The DON acknowledged that wound treatments should have a physician order and that all dressings should be dated, but these practices were not followed. Additionally, the facility's policy provided for review addressed only pressure ulcers and did not include guidance for non-pressure skin conditions. This lack of comprehensive policy, combined with the absence of documentation, assessment, and physician orders for wound care, contributed to deficiencies in the facility's skin and wound management practices for both residents.
Penalty
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