Failure to Timely Identify and Document Scalp Wound
Penalty
Summary
The facility failed to timely and accurately assess, treat, and follow up with a medical provider for a change in condition for one resident who was dependent on staff for most activities of daily living and had intact cognition. The resident was admitted without skin abnormalities, and weekly skin assessments were not consistently documented, with a gap in documentation after an assessment on 7/5. On 7/14, the resident reported a sore area on the back of the head, which was found to be red, warm, and draining. Nursing staff notified the nurse practitioner, who ordered antibiotics, but the resident's son insisted on hospital transfer after observing the wound. The resident was subsequently sent to the hospital by EMS. Hospital evaluation revealed a scalp wound with cellulitis and foul-smelling purulent discharge, with wound cultures showing Staph aureus and Proteus mirabilis. Interviews with facility leadership indicated that the wound was not identified prior to the day of hospital transfer, despite daily care by CNAs and the expectation of weekly skin assessments. The Assistant Director of Nursing acknowledged that the wound should have been identified earlier and that required documentation was missing. The lack of timely identification and documentation of the wound led to the resident's transfer for advanced medical care.