Failure to Assess and Obtain Treatment Orders for Resident's Skin Tears
Penalty
Summary
A deficiency occurred when the facility failed to assess and obtain treatment orders for a resident who developed two skin tears on the left arm. The resident, who had diagnoses including congestive heart failure, severe protein-calorie malnutrition, and pressure ulcers, was observed with two dressings on the left arm. The resident reported waiting for dressing changes and was unsure of the exact circumstances of the injury. Review of the resident's medical record showed no physician orders for treatment of the skin tears and no documented assessment of the wounds. Interviews with nursing staff revealed that standard protocol involves cleaning, assessing, and dressing the wound, followed by notifying the physician and obtaining treatment orders, which are then entered into the resident's treatment record. However, in this case, the registered nurse was unaware of the condition of the wounds under the dressings and confirmed there were no orders or assessments documented. The Director of Nursing also confirmed that such wounds should be tracked and treated according to facility policy, which was not done in this instance.