Failure to Follow Wound Care Protocol and Documentation for Skin Tear
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards, the resident's care plan, and the resident's preferences for one resident with a skin tear. The resident, who was severely cognitively impaired and at risk for skin integrity issues, sustained a skin tear on the right leg. Despite the facility's policy requiring physician notification, obtaining treatment orders, completing an incident report, and documenting a skin assessment, these steps were not followed. The wound was observed with a transparent bandage in place, but there was no documentation of the injury or treatment in the resident's chart prior to surveyor intervention. Interviews revealed that the skin tear was first noticed by a nursing assistant, who reported it to an LPN. The LPN provided first aid and applied a transparent bandage but did not document the incident, notify the resident's family, obtain physician orders, or complete an incident report, citing being too busy. The treatment nurse and nurse practitioner were unaware of the wound until it was brought to their attention by the surveyor. The facility's wound care protocol and care plan required staff to observe, document, and report skin concerns, and to provide treatment as ordered by a physician, but these procedures were not followed in this case. Multiple staff interviews confirmed that the expected process for new wounds included incident reporting, physician notification, obtaining treatment orders, and documentation in the electronic medical record. However, these steps were not completed for the resident's skin tear. The deficiency was identified when the state surveyor intervened, and it was found that the facility failed to follow its own policies and professional standards of practice regarding wound care and documentation.