Failure to Provide and Document Ordered Wound Care and Skin Assessments
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with professional standards for a resident with significant skin integrity issues. The staff did not consistently administer treatments as ordered for non-pressure wounds, failed to complete comprehensive skin assessments on a routine basis, and did not reassess the efficacy of treatments for ongoing skin problems. Documentation was incomplete or missing for weekly skin assessments, and there was a lack of follow-through on physician orders for wound care, application of creams, and use of heel protectors. Staff also failed to accurately document the administration of treatments, sometimes marking them as completed when they were not actually provided. The resident involved had multiple complex medical conditions, including paraplegia, morbid obesity, amputation, kidney failure, and osteomyelitis, and was at high risk for pressure ulcers and other skin breakdown. The resident was dependent on staff for mobility, hygiene, and wound care. Observations revealed that the resident's compression wraps were not being removed at night as required, heel protectors were not in place, and wound dressings were not changed according to schedule. The resident's skin was noted to be extremely dry, cracked, and in some areas bleeding, indicating that current treatments were not effective. Staff interviews confirmed a lack of clarity regarding treatment responsibilities and documentation procedures. Further review showed that shower and bed bath documentation was inconsistent, with missing or incomplete records of skin assessments during these activities. Staff were unsure about the use of certain lotions and the availability of bariatric shower chairs, despite one being present in the facility. The wound nurse and other staff acknowledged that skin assessments and treatments were not always completed as ordered, and that communication and documentation lapses contributed to the deficiencies. The facility's policies required regular skin assessments, accurate documentation, and adherence to physician orders, but these were not consistently followed.