Failure to Monitor Skin Condition and Follow Up on Critical Lab Result
Penalty
Summary
The facility failed to comprehensively assess and monitor a skin condition for a resident who was at risk for skin breakdown due to multiple diagnoses, including diabetes and dementia. The resident had a history of rashes and was noted to have developed red spots on her chin, which were observed by staff but not promptly recognized or documented as a new skin concern. Nursing staff were unaware of the red areas until they were pointed out, and there was a lack of consistent monitoring and communication regarding the skin changes. The care plan included interventions for skin care and monitoring, but staff interviews revealed gaps in awareness and follow-through on these interventions. Additionally, the facility failed to ensure timely follow-up on a critical laboratory result for another resident with complex medical needs, including end-stage renal disease, anemia, and a bleeding disorder. The resident's lab results showed a critically low hemoglobin level, which was flagged as such on the report. Despite established protocols requiring immediate provider notification for critical labs, the nurse who reviewed the result did not contact the provider. Multiple staff interviews confirmed that the critical value was not communicated as required, and there was no documentation of provider notification in the progress notes. The facility's policies directed staff to notify providers of new skin concerns and critical lab results, but these procedures were not followed in the cases reviewed. Staff interviews indicated confusion or lack of awareness regarding the significance of the findings and the required actions. The director of nursing confirmed that the expected process was not followed in both cases, and documentation and communication lapses contributed to the deficiencies identified.