Failure to Provide Timely and Documented Wound Care for Skin Tears
Penalty
Summary
The facility failed to provide care and services for skin tears in accordance with professional standards of practice, as evidenced by multiple instances of incomplete or missing wound assessments, lack of documentation of wound care, and delays in obtaining physician orders for wound treatment. The facility's policy required weekly wound evaluations, but this was not consistently followed for several residents with skin tears. For one resident, skin tear wounds were not properly measured or photographed due to ongoing technical issues with the wound photo application, and there was no documentation on the Treatment Administration Record (TAR) to indicate that prescribed wound care treatments were performed. Additionally, hospital records indicated that dressings had not been changed for an extended period, and the facility was unaware of this until informed during the investigation. Another resident developed a skin tear that was initially treated with a dressing, but a specific physician order for wound care was not obtained until several days later. The Center Nurse Executive confirmed that wound care orders were delayed and that wound assessments were documented, but not in accordance with the required timeline. For a third resident, a skin tear was present upon return from the hospital, but the initial wound assessment was not completed until several days later, and the assessment itself was incomplete, lacking documentation of key wound characteristics such as infection, exudate, and pain. A fourth resident had a skin tear that was not assessed for several weeks, with significant changes in wound size and characteristics going undocumented during that period. The Center Nurse Executive confirmed that there were gaps in wound assessment documentation for this resident as well. These findings demonstrate a pattern of failure to follow established wound care protocols, including timely and complete assessments, documentation of care provided, and prompt initiation of physician-ordered treatments.