Failure to Assess and Monitor Skin Impairment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who had a newly observed skin impairment. Upon admission and readmission, the resident had a history of healed bilateral lower extremity wounds and was noted to have scar tissue with hyperpigmentation. Despite documentation by a nurse practitioner of trace erythema and a blister on the right lower extremity on multiple occasions, licensed nurses repeatedly documented that there was no skin breakdown in the weekly summaries. Additionally, a CNA documented areas of concern on the resident's lower extremities during a daily body check, which was signed by a licensed nurse. There was no evidence in the medical record that a licensed nurse assessed the resident's bilateral lower extremities following the CNA's documentation of skin concerns. The treatment administration record did not show any treatment or monitoring orders for the resident's lower extremity wounds, and no care plan problem was initiated for the documented blister. Interviews with staff confirmed that the expected process was for CNAs to report new skin issues to licensed nurses, who would then assess, document, notify the physician, and initiate monitoring and care planning as needed. However, this process was not followed in this case. The Director of Nursing and other staff acknowledged that there should have been a care plan and monitoring for the resident's blister, and that the required assessments and documentation were not completed. The failure to assess, document, and monitor the resident's skin impairment represented a lapse in providing quality care according to the facility's policies and procedures.