Failure to Assess and Treat Skin Injuries and Monitor Weights for Residents on Diuretics
Penalty
Summary
The facility failed to perform appropriate skin evaluations and implement necessary monitoring and treatment for a resident who sustained skin injuries. One resident was observed with multiple scabs on their knees and shins, which were not being treated. Staff interviews revealed that the injuries were not documented in the resident's weekly skin assessments, and nursing staff were unaware of the injuries. The facility's protocol required that all skin injuries be documented, reported to the provider and family, and treated according to physician orders, but these steps were not followed for this resident. Additionally, the facility did not monitor and obtain daily weights for another resident who was on diuretic therapy. Documentation showed that daily weights were missing for several consecutive days, despite the resident receiving two diuretic medications. Staff confirmed that daily weights should have been recorded for residents on diuretics, but this was not done. These failures were identified through observation, interviews, and record reviews.