Delayed Treatment and Care Plan Update for Facility-Acquired Skin Tears
Penalty
Summary
The facility failed to provide timely treatment for a resident's left lower back and left hip skin tears, and did not update the resident's skin care plan to reflect these new wounds. The resident, who was documented as severely cognitively impaired and dependent on staff for all activities of daily living, acquired the skin tears at the facility due to staff pulling too hard on incontinence briefs or linens, causing a shearing effect. The wounds were first noted by the wound nurse and physician assistant during rounds, and although verbal treatment orders were received, they were not entered until several days later when written orders were provided. As a result, there was a delay in initiating the prescribed wound care treatments. Additionally, the resident's care plan was not updated to include interventions for the newly acquired skin tears, and no incident report or risk management documentation was completed regarding the injuries. Facility policy requires prompt assessment, documentation, and treatment orders for new skin conditions, as well as updates to care plans and incident reporting. These steps were not followed, resulting in a lack of timely intervention and care plan revision for the resident's skin injuries.