Failure to Provide Timely Intervention for New Skin Wound
Penalty
Summary
A deficiency occurred when the facility failed to provide timely interventions for a resident who developed a newly documented open wound on the left shin. The resident had a history of severe cognitive impairment, coronary artery disease, congestive heart failure, Alzheimer's disease, non-Alzheimer's dementia, venous insufficiency, and seborrheic dermatitis. The care plan directed staff to observe the resident's skin during care and report any concerns, including open areas, to the medical team. A physician's order was in place to notify the provider of any new lesions. Despite these directives, a weekly skin assessment identified a new open area on the resident's left shin, but there was no documented intervention or evidence that the physician or family were notified. Further review of nurse progress notes and staff interviews confirmed that the required notifications and interventions were not completed. The LPN involved could not recall if the physician or family had been contacted, and the DON stated that staff should have called the physician, obtained an order, started the order, documented it, and notified the family. The lack of timely notification and intervention for the new wound constituted a failure to follow established care protocols for residents with impaired skin integrity.