Failure to Document Skin Assessments and Provide Ordered Wound Care
Penalty
Summary
The facility failed to complete and document thorough assessments of abdominal bruising for a resident who was receiving daily Plavix and aspirin, both of which increase the risk of bleeding. Multiple nurses and unit managers observed a large, painful bruise on the resident's left lower abdomen but did not document measurements or detailed skin assessments in the electronic medical record. The resident reported significant pain, and the bruise was noted by several staff members over multiple days without proper documentation or timely notification to the nurse practitioner. Laboratory and imaging studies were eventually ordered, but the initial lack of assessment and documentation was evident. Additionally, the facility failed to follow physician orders for daily scheduled treatment of surgical wounds for another resident with a right foot amputation and a history of infection risk. The resident's wound care orders specified daily dressing changes, but documentation showed that wound care was not performed or recorded on several weekend days. The resident reported that his wound dressing had not been changed as ordered, and observation confirmed that the dressing was saturated and dated from a previous day. Nursing staff, including contract nurses, either refused or were unaware of their responsibility to perform wound care, resulting in missed treatments. Interviews with staff, including nurses, the unit manager, the nurse practitioner, the DON, and the administrator, confirmed that wound care orders were not consistently followed and that documentation of care and assessments was lacking. The failures involved both the lack of proper assessment and documentation for a resident at risk of bleeding and the failure to provide and document wound care as ordered for a resident with a surgical wound, as observed and reported by both residents and staff.