Failure to Notify Physician and Responsible Party of Skin Tear
Penalty
Summary
A resident with a history of diabetes mellitus type 2, essential hypertension, and severe cognitive impairment was identified as having limited mobility and was at risk for skin breakdown according to her care plan. During routine care, a CNA was informed by the resident's family member about a skin tear, which the CNA then reported to an LVN. The LVN assessed and cleansed the skin tear but failed to notify the physician or the resident's responsible party, as required by facility policy and professional standards of practice. The LVN stated that the omission occurred because he became occupied with another resident and forgot to make the necessary notifications. The facility's policy required prompt notification of the physician and the resident's representative in the event of a change in condition. The DON and ADON confirmed that the LVN did not follow protocol, resulting in the skin tear not being reported or treated according to physician orders for two days. The resident was at risk for infection due to the delay in appropriate treatment and communication.