Failure to Assess, Monitor, and Treat Skin Conditions and Changes in Condition
Penalty
Summary
The facility failed to provide appropriate medical treatment, monitoring, and assessment for multiple residents with skin conditions and changes in condition. One resident with a complex medical history, including peripheral vascular disease, end-stage renal disease, and multiple wounds, was not comprehensively assessed or treated for new and existing skin tears, vascular wounds, and pressure ulcers. Documentation was lacking for several wounds, and there was no evidence of timely intervention or monitoring following significant changes in the resident’s condition, such as altered mental status, seizure-like symptoms, and declining oxygen saturation. The facility also did not ensure that all wounds were evaluated by the appropriate clinical staff, and there was a lack of documentation regarding wound care and monitoring after hospital readmissions and surgical procedures. Another resident with severe cognitive impairment and multiple comorbidities developed a pressure ulcer and a skin tear, but the facility did not document when or how the skin tear occurred. The facility also failed to obtain or maintain hospice documentation for this resident, despite the resident being under hospice care. Interviews with nursing staff confirmed the absence of documentation and the lack of hospice visit records in the facility. Additional deficiencies were identified for two other residents. One was admitted with a skin condition to the elbow, but the assessment did not specify or evaluate the condition, and there was no monitoring of a skin tear or bruising observed on admission. Another resident, who was on anticoagulant therapy, developed a large bruise after a transfer incident involving a gait belt, but the facility did not measure or monitor the bruise, nor did they report the incident as required. Facility policy required all skin tears to be evaluated, documented, and monitored weekly, but this was not followed in these cases.