Failure to Document and Perform Weekly Wound Assessments as Ordered
Penalty
Summary
The facility failed to provide wound care as directed by the physician for a resident with multiple diagnoses, including peripheral neuropathy, type 2 diabetes, chronic kidney disease, and a history of stroke. The resident had a physician's order for weekly skin checks, including a head-to-toe assessment and re-evaluation of any existing skin concerns every week. Despite this order, documentation showed that weekly re-evaluations of a partial thickness skin tear on the right buttock were not completed or documented on several specified dates. The Treatment Administration Record indicated the order was signed off, but there was no associated documentation of the required assessments. Further review of the resident's skin evaluations over several weeks indicated no change in the wound's size or condition, and the wound continued to be treated with zinc oxide. When the resident requested a skin assessment, the nurse examined the area and notified the Nurse Practitioner, who ordered new topical treatments. However, there was no documentation of a skin assessment on the date of this request. Facility policy required weekly skin assessments and documentation, including detailed wound descriptions, but interviews with facility leadership confirmed a lack of documentation regarding the required weekly skin check re-evaluations for the resident's wound.