Failure to Provide Wound Care and Complete Skin Assessments
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents reviewed for wound care and weekly skin assessments. For one resident with a history of heart failure, multiple sclerosis, dementia, and diabetes, the facility did not complete weekly skin assessments as required by policy. This resident, who had a history of hemorrhoids and was receiving topical medication, was admitted to the hospital with a perianal abscess that required surgical intervention and IV antibiotics. Facility documentation did not show that skin assessments were performed from early to late October, and there was no documentation of the resident's hemorrhoids in the care plan. Another resident, who had quadriplegia, acute renal failure, dementia, and a dysfunctional bladder, was admitted with stage 3 pressure wounds and an indwelling Foley catheter. The facility did not enter or initiate physician's orders for wound care as outlined in the hospital discharge instructions. There was no documentation of wound care being provided or skin assessments being completed after the initial wound care note, despite the resident having significant skin breakdown upon hospital readmission. Interviews with facility staff, including the DON and wound care nurse, confirmed that required wound care orders were not entered or followed, and that skin assessments were not completed as per facility policy. The breakdown in communication and documentation led to a lack of appropriate wound care and monitoring for both residents, resulting in unaddressed and worsening skin conditions.