Failure to Communicate New Skin Impairment to Wound Care Team
Penalty
Summary
A deficiency occurred when a new skin impairment on a resident's right great toe was not promptly communicated to the wound care team according to facility protocol. The resident, who had a history of acute and chronic respiratory failure and an ingrown nail, developed a blackened area on the toe after a podiatrist attempted but was unable to fully remove the ingrown nail due to pain. The resident reported the toe discoloration and pain to multiple staff members, but did not receive a response. A CNA noticed the blackened area and reported it to an LPN, but there was no evidence that the LPN communicated this to the wound care team. The CNA also did not complete the required 'Stop and Watch' form to document the change in condition. The wound care nurse and the assistant director of nursing confirmed that the facility's protocol required immediate reporting of new skin impairments to the wound care team for timely intervention. The delay in communication resulted in a delay in the wound care team being notified and in the initiation of appropriate interventions. Facility policy required daily skin checks by CNAs and weekly evaluations by licensed nurses, but these protocols were not followed, leading to a delay in addressing the resident's skin impairment.