Failure to Document and Complete Daily Skin Tear Treatment per Standing Orders
Penalty
Summary
The facility failed to ensure that treatment for a non-pressure related skin impairment was completed daily according to standing orders for one resident with a skin tear. The resident, who had a history of hemiplegia, hemiparesis, and Parkinsonism, sustained an abrasion to the right shin while being assisted to the toilet by a family member. The injury was initially assessed and treated by a nurse using the facility's standing orders, which required daily dressing changes and documentation on the Treatment Administration Record (TAR) until the area was healed. However, a review of the resident's TAR revealed that no treatment order for daily dressing changes was entered, resulting in the dressing not being changed as required. Observations showed the same bandage remained in place for several days, and interviews with nursing staff confirmed that the standing order had not been properly documented on the TAR. Both the nursing staff and the RN Supervisor acknowledged that the nurse responsible for initiating the standing order should have entered the treatment order on the TAR to ensure daily care was provided and documented.