Failure to Document and Treat Non-Pressure Skin Issues
Penalty
Summary
A deficiency occurred when a resident with dementia and moderate protein calorie malnutrition developed scabs and bruises on the left arm, which were observed by a surveyor over several days. The resident was unable to provide a clear explanation for the injuries due to severely impaired cognition. Despite multiple observations of the skin issues, there was no documentation in the resident's progress notes or treatment records regarding the bruising, scabs, or redness on the left arm. The only documented skin issue was related to a left lower leg wound, for which there was an active treatment order. The facility's care plan directed staff to inspect the resident's skin weekly and as needed, and to report any changes such as redness, open areas, scratches, cuts, or bruises to the nurse. However, skin checks and ADL task documentation did not reflect the presence of new skin issues on the left arm, and no treatment orders were initiated for these injuries. Interviews with nursing staff and CNAs confirmed that their protocol was to notify the nurse and document any new skin issues, but this process was not followed in this case. Additionally, the facility's policy required daily skin inspections during personal care and ADLs, with evaluation, reporting, and documentation of any changes. Despite this, the observed skin issues on the resident's left arm were neither documented nor addressed according to facility policy. The DON was unable to provide a specific policy on skin issues when requested, further highlighting a gap in adherence to established procedures.