Failure to Implement Individualized Skin Protection Interventions
Penalty
Summary
Facility staff failed to follow their own policy regarding the implementation of individualized interventions for skin protection for a resident with multiple pressure wounds. The resident, who was admitted with diagnoses including paraplegia, pressure ulcers, and contractures, required staff assistance for all activities of daily living. Upon review, the resident was found to have numerous wounds, including stage three and four pressure ulcers on various parts of the body. Despite these findings, the care plans only included general interventions such as monitoring skin during care and notifying nurses of changes, as well as evaluating and treating per physician orders. No additional individualized interventions or care plans were implemented to address the resident's specific skin management needs, as required by facility policy. The facility's Skin Protection Guideline policy mandates the identification of at-risk residents and the prompt implementation of individualized interventions to prevent and treat skin breakdown. However, the care plans for this resident did not reflect individualized strategies or a turning and repositioning schedule, despite the presence of multiple wounds. When questioned, the DON acknowledged that nurses were responsible for implementing wound and skin management interventions but did not provide further explanation or documentation regarding the lack of individualized care plans and interventions for the resident.