Failure to Implement Care Plan Interventions for Skin Integrity
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, heart failure, and major depressive disorder, was not provided with all the care plan interventions necessary to maintain skin integrity. The resident, who had severely impaired cognition and required partial assistance with activities of daily living, had an individualized comprehensive care plan (ICCP) that included interventions such as keeping the skin clean and dry, daily skin inspection, notifying the physician of any skin breakdown, turning and repositioning every two hours, and monitoring for changes in circulation. Despite these interventions being documented, the facility failed to ensure that the daily skin inspection was implemented as required. The issue came to light after the resident's representative reported multiple complaints about the resident's skin condition, including irritations, upon discharge. Interviews with the DON and MDS Coordinator revealed confusion regarding the implementation of the daily skin inspection intervention, with staff believing it was either an automated entry or should be performed visually during care without specific documentation. The facility's policy required interventions to be clear, concise, and measurable, but the lack of clarity and proper implementation led to the deficiency.