Delayed Physician Notification and Incomplete Skin Assessments Result in Harm
Penalty
Summary
The facility failed to provide timely physician notification and accurate skin assessments for residents with significant skin and wound care needs. In one case, a resident with a history of myocardial infarction, sepsis, and diabetes developed signs of dry gangrene in the left foot and ankle. Despite documentation of black and painful areas on the left foot and ankle, the physician was not notified promptly. The nurse placed a note in the doctor’s book and deferred notification to the morning shift, resulting in a delay. The physician was not made aware of the resident’s condition until two days later, at which point the resident was sent to the hospital and required an above-knee amputation due to dry gangrene and acute limb ischemia. Additionally, the facility failed to ensure the accuracy and completeness of skin assessments for two residents. For one resident, skin assessments were not performed weekly as indicated by the care plan, and documentation was inconsistent, with gaps in assessment records and failure to note significant changes. For another resident, the admission assessment and subsequent skin evaluations were incomplete and inconsistent, omitting documentation of surgical wounds, soft heels, and elbow wounds, despite these being present and referenced in hospital discharge paperwork. The DON confirmed that not all skin impairments were documented, and there was no evidence of monitoring or documentation for surgical incision sites. Interviews with staff, including the DON, LPN, and wound nurse, revealed a lack of adherence to facility policy and nursing standards regarding comprehensive skin assessments and documentation. Staff acknowledged that all skin impairments, regardless of size or type, should be documented and monitored, but this was not consistently done. The facility’s own policies required comprehensive skin assessments upon admission and as indicated, but these were not followed, leading to missed or delayed identification and treatment of significant skin and wound issues.