Failure to Follow Professional Standards in Skin Tear Treatment
Penalty
Summary
The facility failed to ensure that professional standards of nursing were followed in the treatment of a skin tear for one resident. The resident, who had diagnoses including Alzheimer's disease, dementia with behavioral disturbance, and pressure-induced deep tissue damage, was care planned for potential skin integrity impairment due to limited mobility and incontinence, with interventions such as derma sleeves for arm protection. However, during multiple observations, the resident was seen with a bandage on her left forearm that lacked a date and initials, and no derma sleeves were present on her arms as required by her care plan. Review of records showed documentation of derma sleeves on the Treatment Administration Record, but this was not consistent with direct observation. Additionally, there was no physician order for a dressing for the resident's left forearm skin tear, despite the presence of a bandage. Interviews with nursing staff confirmed that the bandage should have been dated and initialed, and that the wound nurse was not involved unless the skin tear was significant. The Director of Nursing acknowledged the resident's fragile skin and the need for protective interventions, but these were not observed in practice. These findings indicate a failure to follow professional standards and care plan interventions for skin integrity and wound care.