Lack of Comprehensive Care Plan for Resident with Skin Condition
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident diagnosed with psoriasiform dermatitis. During observations, the resident was found lying in bed with scaly, shedding skin on her shoulders, arms, torso, and legs, and there were visible dry skin flakes and dark discoloration spots on the bed linens. The resident expressed a need to be changed and indicated discomfort. Certified Nursing Assistants confirmed the presence of a skin condition and provided care, but the resident's record review revealed no care plan addressing the skin condition. The resident's diagnoses included diabetes mellitus and psoriasiform dermatitis, and a physician's order was in place for the application of Tacrolimus cream to affected areas twice daily. Despite this, the care plan did not reflect interventions or monitoring related to the skin condition. The deficiency was confirmed when the Director of Nursing was notified, and no care plan had been provided by the end of the survey.