Failure to Document and Care Plan for Skin Injuries and Hospice Services
Penalty
Summary
The facility failed to provide necessary care and services for non-pressure skin injuries for two residents. One resident had a provider order for wound care to the left buttock, but the type of wound was not documented in the electronic health record (EHR), and the care plan did not specify the wound or include weekly assessments as required. Staff interviews confirmed the absence of documentation regarding the wound type and status, and the care plan lacked details about the wound and related pain management interventions. Another resident developed a skin tear and hematoma on the right-hand middle finger, which was observed and reported by the resident and staff. Although the injury was cleaned and bandaged, there was no provider order for treatment, and the care plan did not reflect the actual skin impairment. Staff acknowledged that treatment orders and care plan updates were missing and that this did not meet expectations. Additionally, the facility failed to develop a comprehensive, collaborative care plan involving Hospice services for a resident receiving end-of-life care. The resident's care plan did not include any information about Hospice, despite documentation in the EHR and Minimum Data Set (MDS) assessments indicating Hospice care. Staff interviews confirmed the omission of Hospice care planning and recognized that the care plan should have been updated to reflect the resident's current needs.