Failure to Investigate, Document, and Implement Interventions for Skin Tears and Falls
Penalty
Summary
The facility failed to ensure that areas were free from accident hazards and did not provide adequate supervision to prevent accidents for three residents. For one resident with multiple diagnoses including stage 4 pressure ulcer, dementia, and a history of fractures, there were repeated incidents of skin tears during her stay. Family members reported that the resident sustained skin tears during care, including while being assisted with a shower and when a handrail was lowered onto her hand. Staff interviews revealed a lack of awareness about the injuries, and there was no documentation or incident report completed at the time of the injuries. The facility only initiated an investigation after the surveyor's inquiry, and the required assessments and documentation were not completed as per facility policy. Another resident with severe cognitive impairment and multiple comorbidities experienced several skin tears over a period of time. Progress notes documented new skin tears, but neither the resident nor staff could consistently identify the cause. Despite these incidents, the care plan was not updated with new interventions to prevent further skin tears, and the Director of Nursing confirmed that no additional interventions were added after the injuries occurred. A third resident, identified as high risk for falls due to a history of fractures and other medical conditions, experienced multiple falls within a short period. Documentation showed that the resident was found on the floor several times, sometimes with injuries such as a swollen and bruised ankle. Although the care plan included specific fall prevention interventions, direct observation revealed that these interventions, such as a motion alarm, non-slip pad, and signage, were not in place. Staff present in the room were unaware of the required fall precautions, and the Director of Nursing was uncertain about which interventions should be in use. Facility policies required prompt reporting, assessment, and implementation of interventions for skin conditions and falls, but these were not consistently followed.