Failure to Complete Skin Assessments and Follow Wound Care Orders
Penalty
Summary
The facility failed to accurately complete a resident's skin assessment sheet and did not follow a physician's order for wound treatment. Upon admission, the resident, who was cognitively impaired, immunocompromised, and had multiple comorbidities, was documented as having several pressure ulcers. However, subsequent weekly skin assessments were not consistently completed, with missing or incomplete documentation on several dates. Additionally, the care plan listed multiple areas of impaired skin integrity, but the skin assessment sheets did not reflect all wounds, and some wound areas were not documented at all during certain assessments. Review of the Treatment Administration Record (TAR) revealed that a prescribed antiseptic wound medication was not signed off as administered on multiple occasions, and treatment for a left buttock wound was not ordered until several days after admission. The DON confirmed that skin assessments should be completed weekly and that nurses are responsible for signing off treatments, but acknowledged that these processes were not followed. These deficiencies were identified through record reviews and staff interviews during the survey.