Failure to Follow Physician Orders and Facility Protocols for Skin Care and Wound Management
Penalty
Summary
The facility failed to provide necessary care and services in accordance with residents' care plans, physician orders, facility protocols, and professional standards of practice for two residents reviewed for quality of care. For one resident with cognitive and communication impairment and a high risk for skin impairment, staff observed redness and a fungal rash under both breasts. Although there was a physician order for Nystatin powder to be applied twice daily, the LPN had not applied it as ordered, and instead, a CNA applied Vitamin D ointment, which was not appropriate for a fungal rash. The wound care nurse initiated the treatment order but did not document a written assessment, update the care plan in a timely manner, or notify the family of the treatment. There was also a delay in obtaining the treatment order after a concern was raised by the resident's home care case manager, and no documentation of the initial assessment was found in the medical record. For another resident with multiple comorbidities, including a left above-the-knee amputation, diabetes, and high risk for skin impairment, the facility did not follow physician orders for wound care. During wound care observation, the LPN applied Nystatin powder to the sacral area, which was not ordered for that site, and did not apply skin prep as required by the physician's order. The LPN also applied Nystatin powder to the perineal area, which was consistent with the order, but the wound care for the right hip was performed as ordered. Documentation and care plan updates were not completed as required by facility policy, and the wound care nurse did not ensure that all new skin impairments were assessed, documented, and communicated to the physician and family. Facility policies require prompt identification, documentation, and treatment of skin breakdown, adherence to physician orders, and timely updates to care plans. In both cases, there were failures to document skin assessments, follow physician orders for wound care, update care plans, and notify family members as required by facility protocol. These actions and inactions led to the identified deficiencies in the provision of care and services for the affected residents.