Failure to Complete Skin Assessments and Timely Wound Care Notification
Penalty
Summary
The facility failed to complete weekly skin assessments and to identify and document a Stage II pressure ulcer for one resident, as well as failed to notify the physician and obtain treatment orders for the wound. The resident, who was cognitively intact but dependent on staff for activities of daily living and incontinent of bowel and bladder, was at risk for pressure ulcers and had multiple comorbidities including heart failure, kidney disease, respiratory disease, and diabetes. There was no documentation of weekly skin integrity assessments for over a month, and new open areas on the resident's left buttock were not identified or reported until observed by the wound nurse. The wound nurse did not notify the physician, the resident's responsible party, or the DON of the new wounds, nor did she document a wound assessment or obtain new treatment orders in a timely manner. Another resident was admitted with existing pressure ulcers to the sacrum, gluteal area, and bilateral heels, but there was no documentation of wound measurements or treatment orders for these areas upon admission. The progress notes and medication records did not reflect any treatment orders for the pressure ulcers until several days after admission, despite the presence of hospital discharge orders for wound care. The wound nurse and DON confirmed that staff did not notify them of the wounds upon admission, and the wounds were only addressed after management reviewed hospital paperwork and initiated a skin assessment. Interviews with staff revealed that CNAs and nurses were expected to report and document new skin issues immediately, but this did not occur in either case. The facility's policies required comprehensive skin assessments on admission and weekly thereafter, as well as prompt notification of the physician and responsible parties when new wounds were identified. These procedures were not followed, resulting in delayed identification, documentation, and treatment of pressure ulcers for both residents.