Failure of Medical Director to Implement and Coordinate Skin Care Policies
Penalty
Summary
The facility failed to ensure that the Medical Director fulfilled responsibilities related to the implementation of resident care policies and coordination of medical care, specifically regarding the total skin program. A resident was admitted with a high risk for pressure injury but had no existing skin issues on the sacrum at admission. The care plan identified the risk but only included general interventions, lacking individualized measures such as turning, repositioning, or the use of an air mattress. Despite ongoing documentation by the APRN of sacral redness and pain, and repeated requests for an air mattress, no new interventions were added to the care plan, and the resident's condition was not escalated appropriately. The APRN noted the development of a sacral pressure injury and documented the need for specific wound care and an air mattress, but did not follow the process of communicating these findings to the nurse on the unit or the DON. The DON was unaware of the wound until it had worsened significantly, and there was no timely referral to the wound care specialist or updates to the care plan. The resident experienced significant pain and was eventually transferred to the hospital, where they died from complications related to the sacral pressure injury. The Medical Director, who was also the resident's physician, was not aware of the resident's skin issues or the facility's failure to implement pressure injury prevention and treatment policies. The Medical Director had not reviewed the APRN's notes or discussed concerns with her, and there was no evidence of coordination between the Medical Director, the APRN, and the facility staff regarding the resident's care. Facility policy required the Medical Director to coordinate care and monitor quality, but there was no documentation that these responsibilities were fulfilled in this case.