Failure to Implement Comprehensive Skin Assessment and Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including Alzheimer's disease, chronic kidney disease, COPD, dementia, and cancer. The care plan for impaired skin integrity specified that weekly skin assessments were to be performed, but there was no evidence that these assessments were consistently completed. Documentation showed that while showers and bed baths were recorded, no new skin issues were identified, and there was a lack of head-to-toe skin assessments by nursing staff. The wound care physician assistant only assessed the resident's head wound and did not perform a full skin assessment, as she was directed by the DON to focus on specific areas or residents. Interviews with various nursing staff, including LPNs and RNs, revealed that they did not conduct comprehensive weekly skin assessments, as this responsibility had been delegated to the wound care staff by the DON. Review of the Treatment Administration Record indicated that preventive treatments for the resident's heels were not documented as provided on certain dates. This lack of thorough and regular skin assessments led to unrecognized and untreated skin breakdown. The deficiency became evident when the resident was admitted to a hospital with multiple, previously unidentified areas of skin breakdown, including eschar on both heels, stage III pressure ulcers on the buttocks, a non-pressure chronic ulcer of the heel and midfoot, and an unstageable pressure ulcer of the sacral area. The hospital records indicated that these wounds required surgical intervention. The facility's own policy required ongoing assessments and timely revisions to care plans, but these were not followed, resulting in the failure to prevent or identify significant skin integrity issues.