Failure to Assess, Monitor, and Document Bruises and Wounds; Failure to Implement Wound Orders
Penalty
Summary
The facility failed to ensure that bruises and non-pressure wounds were adequately assessed, monitored, and documented for two residents. One resident, who had multiple risk factors including cancer, diabetes, obesity, recent surgery, and was on anticoagulant therapy, was observed with significant bilateral bruising on her upper arms and an open area near her left armpit. Despite these findings, there was no documentation or treatment instruction for the open area, nor was there specific assessment or monitoring for the bruising. Multiple skin and wound assessments, daily skilled notes, and care plans lacked detailed information regarding the size, color, or progression of the bruises, and there was no evidence that the bruises were being monitored or that their resolution was tracked. Staff interviews confirmed that the bruises and open area had not been documented or measured as required by facility policy. Additionally, the same resident's care plan and physician orders required daily and weekly skin assessments, monitoring for signs of bleeding, and prompt treatment of skin breaks. However, documentation did not reflect that these interventions were consistently implemented. The facility's policy required notification of the provider, treatment orders, and care plan updates for significant skin alterations such as large or multiple bruises, but these steps were not followed. Staff interviews revealed a lack of clarity and consistency in how bruises and wounds were assessed, documented, and communicated among the care team. A second resident, with severe cognitive impairment and multiple comorbidities, had a physician order for wound care to the scrotum using a specific dimethicone-based cleanser following a recent hospitalization. However, this order was not reflected on the medication or treatment administration records, and staff were unaware of the specific product required, instead using alternative products without the ordered active ingredient. Interviews with nursing staff and review of records confirmed that the wound care order was not implemented or clarified, and the care provided did not match the provider's instructions. The facility's policy required staff to follow and clarify orders as needed, but this was not done in this case.