Failure to Manage Non-Pressure Skin Alteration and Obtain Daily Weights
Penalty
Summary
The facility failed to appropriately manage and document the treatment of a non-pressure skin alteration for one resident and did not obtain daily weights as ordered for three residents. For one resident with multiple comorbidities, including heart failure, diabetes, and chronic kidney disease, there was an incident involving trauma to the right third and fourth toes. The initial wound assessment and documentation were incomplete, as only the third toe was documented and treated, while the fourth toe was not described or treated at the time of discovery. The cause of the trauma was not documented, and subsequent wound care orders did not accurately reflect the areas requiring treatment. Additionally, there were days when prescribed dressing changes were not completed for the affected toes. The same resident, along with two others with diagnoses such as heart failure, dementia, and risk of fluid imbalance, had active physician orders for daily weights due to their medical conditions. However, the facility failed to obtain and document daily weights on multiple occasions for all three residents. There was no documentation to indicate that the missed weights were due to resident refusals or any other justifiable reason; rather, the weights were simply not obtained as required by physician orders. Interviews with facility staff, including the wound nurse and the Director of Nursing, confirmed the lack of documentation and the failure to follow through with both wound care and daily weight monitoring as ordered. The deficiencies were identified through interviews and record reviews, and the facility census at the time was 47 residents.