Failure to Complete and Document Wound Care and Skin Assessments
Penalty
Summary
The facility failed to ensure that wound care treatments and skin assessments were completed and documented as ordered for one resident with a history of cerebral palsy and peripheral vascular disease. The resident had multiple physician orders for wound care, including the application of protective gels and ointments to various areas on the lower extremities and feet. Review of the Treatment Administration Record (TAR) revealed numerous instances where treatments were either missed or lacked documentation across different shifts throughout March and April. Additionally, weekly skin assessments were not consistently completed, with a gap noted between 4/10/25 and 4/21/25. Interviews with nursing staff and the Director of Nursing (DON) confirmed that while treatments may have been performed, they were not always documented as required. Staff cited workload and time constraints as reasons for incomplete documentation, and there was uncertainty regarding whether treatments were consistently administered. The DON acknowledged responsibility for ensuring completion and documentation of both treatments and skin assessments, and staff were expected to follow established schedules and policies for wound care and assessment. The resident involved was cognitively intact and had a care plan addressing limited mobility and chronic wounds, including the use of protective boots and regular monitoring for skin issues. Despite these interventions, the facility did not adhere to its own policies for wound assessment and treatment documentation, resulting in missed or undocumented care for the resident's chronic wounds and skin conditions.