Failure to Ensure Weekly Skin Assessments and Oversight of Wound Management
Penalty
Summary
Administration failed to ensure that staff performed weekly skin assessments and wound treatments as ordered, and did not provide adequate oversight and monitoring of the skin integrity program. This deficiency affected six residents who were either at risk for skin breakdown or had existing wounds. Specifically, weekly skin inspections were not implemented for two residents, and interventions for routine weekly skin assessments were not developed for four other residents at risk for skin breakdown. Additionally, licensed nursing staff did not consistently perform or document weekly skin assessments and treatment orders for several residents. The facility also did not utilize an effective Quality Assurance and Performance Improvement (QAPI) process to identify and address concerns related to the wound management system. Despite recommendations from the Regional Nurse Consultant to develop a Performance Improvement Plan after identifying problems with the skin management program, there was no indication that such a plan was created. Staffing instability was noted, with five treatment nurses employed over several months and periods when only one treatment nurse was available, making documentation and wound care challenging.