Failure to Address and Document Skin Impairments and Physician Orders
Penalty
Summary
The facility failed to ensure that skin conditions and impairments for a resident were appropriately addressed, that physician orders for skin impairments were obtained and followed, and that reasons for not following orders were documented. The resident in question had a history of colon cancer, muscle weakness, and difficulty walking, and was noted to be frequently incontinent. Initial skin assessments documented pitting edema in the lower extremities and a surgical drain, but no other skin impairments. However, subsequent progress notes revealed the presence of a fluid-filled blister on the right hip, which was cleaned but not reported to the physician for further assessment or orders. Later, a ruptured blister was found on the left hip, for which the physician was notified and an order was received and followed, but there was no documentation explaining why the previous order for a different treatment was not followed, nor was there evidence that the physician was notified of the change or the status of the right hip blister. Further review of the treatment administration records showed inconsistencies in the documentation and execution of physician orders related to skin assessments and wound care. Orders for regular skin assessments and specific wound treatments were not consistently documented as completed, and there was no explanation for deviations from prescribed care. Interviews with nursing staff revealed a lack of recall regarding the resident and the events in question, and the physician stated he was not informed about the hip blisters, as there was no documentation or communication from the facility regarding these wounds. Additionally, the Certified Nursing Aide (CNA) accountability logs for the relevant period contained multiple blanks for essential care tasks, including documentation of interventions related to skin care, repositioning, and hygiene. The CNA assigned to the resident during the period in question did not sign the accountability log on several days and could not recall the resident or the events. Facility management was unable to clarify whether the hip blisters were facility-acquired wounds, and there was no evidence that the required assessments, notifications, and documentation were completed as per facility policy and state regulations.