Failure to Provide Consistent Skin and Bowel Care per Facility Policy
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents, specifically in the areas of skin evaluations, care planning, monitoring, and necessary treatment. For one resident with diagnoses including type 2 diabetes mellitus, polyneuropathy, and protein-calorie malnutrition, there was a lack of consistent weekly skin assessments and diabetic nail care as required by facility policy. The resident was found to have a wound on the bottom of the right foot and a wound on the right ear, neither of which had been previously documented or addressed in the care plan. Staff interviews and record reviews confirmed that weekly skin checks and diabetic nail care were not performed or documented from February to May, except for two isolated dates, despite the resident's high risk for skin breakdown and complications due to their medical conditions. Another resident experienced a failure in the monitoring and management of constipation. Bowel documentation showed that the resident did not have a bowel movement for several days, and although there were physician orders for as-needed bowel management medications, these were not administered during the period of constipation. Nursing progress notes did not address the resident's constipation or indicate whether medications were given or refused. Staff interviews confirmed that the facility's bowel protocol, which should be followed when a resident has not had a bowel movement for three days, was not implemented in this case. These deficiencies were identified through observation, interviews, and record reviews, revealing that the facility did not follow its own policies and professional standards for wound management, diabetic foot care, and bowel management. The lack of consistent assessments, documentation, and timely interventions placed the affected residents at risk for unmet care needs and related complications.