Failure to Consistently Treat and Document Dry Skin Condition
Penalty
Summary
A deficiency occurred when a resident with a history of pressure ulcers, heart failure, and hemiparesis developed dry, itchy, and visibly flaky skin on his arms and legs. The resident's care plan included interventions to moisturize dry skin, and a physician's order directed the application of CeraVe cream twice daily. However, observations and interviews revealed that the prescribed cream was not consistently applied, and the resident reported that staff were not regularly treating his dry skin as ordered. Review of the Medication Administration Record (MAR) showed that the CeraVe cream was frequently not administered, with staff documenting 'Drug/Item Unavailable' on multiple occasions. Despite the lack of CeraVe, there was no documentation of an alternative cream being used, even though the physician's order allowed for an alternative topical cream. Staff interviews confirmed inconsistent application of lotion, uncertainty about which products were being used, and a lack of communication regarding the unavailability of the prescribed product. The medical record lacked evidence of provider notification, order clarification, or attempts to obtain the prescribed cream after insurance denial. Nursing leadership confirmed that the CeraVe was not available and that staff had been using A&D ointment instead, without updating the provider or the MAR to reflect this substitution. There was no documentation of what products were actually applied, and the facility's policy did not provide clear guidance for treating non-wound skin concerns like dry skin. The lack of consistent treatment and documentation resulted in the resident's ongoing dry skin condition, with no evidence of improvement over several weeks.