Failure to Implement Care Plan Interventions to Prevent Skin Injury
Penalty
Summary
The facility failed to implement a resident-centered care plan for a resident with a known risk for skin injury. Despite having a documented care plan and provider order for the application of Geri Gloves to both arms each morning and removal each evening to prevent skin injury, observations on two consecutive days showed the resident was not wearing the prescribed Geri Gloves. The resident was observed with a wound dressing on the right elbow, and the resident's representative reported that the resident sometimes sustains skin tears from falls. Further review of the resident's records confirmed the care plan included the intervention of Geri Gloves, yet staff interviews revealed that the gloves had not been seen in use for over a year. The geriatric nurse aide specifically stated never having seen the resident with Geri Gloves, indicating a failure to implement the care plan intervention as ordered and documented.