Failure to Provide and Document Skin Integrity Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate care and documentation for skin integrity issues for two residents. One resident, with a history of end stage renal disease, diabetes, and on antiplatelet medication, was observed with untreated skin tears on the right forearm and left hand. The resident reported that the wounds had not been cleaned or dressed by nursing staff, and that the injuries continued to bleed, especially given their medication that increased bleeding risk. Review of the medical record showed no treatment orders or documentation of skin assessments on several required dates, and there was no evidence that the resident’s physician or family had been notified of the new skin impairments. The care plan included general interventions for skin integrity and antiplatelet medication monitoring, but these were not followed in practice for the observed injuries. Another resident, with contractures, dry skin, and limited mobility, was observed with an open, bleeding wound on the right hand. The resident was noted to be in pain and uncomfortable, and blood was seen on their bed linens. Staff were notified of the bleeding, but subsequent observations showed continued bleeding and open wounds without evidence of treatment. The care plan identified a moderate risk for skin alteration but did not include specific interventions for prevention or care of skin impairments. The treatment administration record did not show any treatment for the right hand wound, and although a physician had previously requested notification of changes to the skin, there was no documentation of such notifications or interventions. In both cases, the facility did not ensure that care and services for skin integrity were provided according to professional standards of practice. There was a lack of timely assessment, treatment, documentation, and communication with physicians and families regarding new or ongoing skin issues. This failure resulted in residents having untreated, actively bleeding wounds and unmet care needs.