Failure to Assess, Monitor, and Follow Up on Skin Injuries and Changes
Penalty
Summary
Three residents experienced failures in assessment, monitoring, and follow-up of skin conditions and injuries. One resident, with a history of metabolic encephalopathy and diabetes, sustained burn injuries from a hot beverage spill. Upon return from the hospital, there was no evidence that treatment for the burns was initiated or monitored for several days, and a follow-up appointment with a burn specialist, as recommended by the hospital, was not arranged in a timely manner. Documentation gaps were noted, and staff interviews confirmed that the treatment nurse was not informed of the incident until four days later, delaying necessary wound care and evaluation. Another resident, with dementia, diabetes, and on long-term aspirin therapy, developed significant bruising on both hands. The skin changes were identified by a CNA and reported to nursing staff, but there was no documented assessment, monitoring, or referral to a physician for further evaluation and treatment. The care plan and physician orders required monitoring for signs of bleeding and prompt reporting, but these steps were not followed. Staff interviews confirmed that the bruising was not properly assessed or documented, and the DON acknowledged that the required protocols were not adhered to. A third resident, with diabetes and peripheral vascular disease, had known diabetic ulcers on both feet. Over a two-week period, the size of the wounds increased, but this change in condition was not identified or communicated to the physician. Weekly wound documentation failed to note the progression, and staff interviews revealed that the increase in wound size should have been recognized as a change in condition and reported. The DON confirmed that the lack of timely communication and documentation could have led to a delay in appropriate care.