Failure to Identify and Address Grievance Regarding Wound Care
Penalty
Summary
The facility failed to identify, document, and address a grievance in accordance with its policy for a resident who was admitted following a fall and had multiple complex medical conditions, including dementia, repeated falls, ataxia, diabetes, COPD, cirrhosis, malnutrition, and depression. Upon admission, the resident had several skin impairments, including a left elbow skin tear, a deep tissue injury to the sacrum, and a bruise to the left hip, as well as multiple bruises and scabbing on various parts of the body. Facility-acquired skin tears were later documented on the shoulders, right forearm, and head. On one occasion, the Wound Care Nurse observed significant bloody drainage from a right forearm wound but did not notify the physician or Nurse Practitioner despite the change in wound status. The resident's spouse voiced concerns to the Social Service Director about poor wound care, specifically mentioning dried blood leaking through the resident's shirt and subsequently requested a transfer to another facility. The Social Service Director acknowledged not reporting this grievance to the Administrator or Assistant DON. There was no documentation in the facility's grievance records that the spouse's concerns were reported, investigated, or resolved. Both the Administrator and Assistant DON confirmed they had not received any report of a grievance related to the resident's wound care. The facility's grievance policy requires prompt resolution of all grievances related to care and treatment, but this process was not followed in this case.