Failure to Complete Skin Assessments and Notify Physician of New Wound
Penalty
Summary
The facility failed to complete weekly skin assessments and did not identify or document an open wound caused by cellulitis on a resident. There was no documentation of weekly skin integrity data collection assessments for over a month, and the facility did not notify the resident's physician or obtain new orders for wound care when a new wound was discovered on the resident's left posterior thigh. The wound was not assessed or documented in the medical record, and the responsible party and Director of Nursing were not notified as required by facility policy. The resident involved had multiple medical conditions, including heart failure, kidney disease, respiratory disease, diabetes mellitus, and was dependent on staff for most activities of daily living. The resident had a history of multiple wounds, including a significant wound on the right thigh, and was at high risk for skin breakdown. Despite these risks, the facility did not ensure that weekly skin assessments were completed or that new wounds were promptly identified, assessed, and communicated to the physician for appropriate treatment orders. Additionally, the facility failed to discontinue outdated wound care orders and documented inaccurately in the Treatment Administration Record (TAR), showing treatments as administered under multiple, conflicting orders. This resulted in false documentation and confusion regarding which wound care orders were current. The wound nurse acknowledged not discontinuing previous orders and not documenting the new wound or notifying the physician in a timely manner, contrary to facility policy and expectations.