Failure to Document and Obtain Treatment Orders for Skin Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to document and obtain treatment orders for a resident at risk for skin breakdown who reported redness and burning to her buttock area. The resident, who was cognitively intact and required substantial assistance for toileting, complained of being left in urine and feces for extended periods during the night shift, sometimes waiting 5-6 hours for incontinence care after activating her call light. During incontinence care, redness and a dressing were observed on the resident's buttocks, and upon further inspection, three open areas surrounded by denuded skin were noted. The wound nurse acknowledged seeing redness the previous day and applying a dressing but did not document the assessment or obtain treatment orders at that time. The resident's care plan indicated she was at risk for skin breakdown and required her skin to be kept clean and dry, with any changes reported to the physician. However, the wound summary lacked measurements, and there was no documentation of the initial assessment or treatment orders prior to the surveyor's observation. Staff interviews confirmed that prolonged exposure to moisture contributed to the skin damage, and the resident's complaints about delayed care were consistent with the observed condition.