Failure to Evaluate and Monitor Resident Wounds per Policy
Penalty
Summary
Facility staff failed to properly evaluate and monitor open lesions for one resident with significant risk factors for impaired skin integrity, including impaired mobility, incontinence, and anemia. The resident's care plan included interventions such as weekly skin assessments, use of pressure reduction devices, and prompt notification of providers for skin concerns. However, record reviews showed that open wounds on the resident's buttocks and gluteal area were not consistently evaluated or measured as required. Several weekly skin assessments lacked documentation of wound measurements, and in some instances, the wounds were not evaluated at all. Direct observation confirmed the presence of multiple open wounds on the resident's buttocks and upper thigh, with staff interviews revealing a lack of awareness regarding the treatment for these wounds. The facility's own policy required comprehensive weekly skin assessments with detailed documentation, including wound measurements and descriptions, which was not followed. The unit manager confirmed that the wounds had not been measured weekly as required by policy.