Failure to Monitor Non-Pressure Skin Wound
Penalty
Summary
The facility failed to monitor a non-pressure skin wound for one resident who was admitted with diagnoses including heart failure and diabetes. Upon admission, a clinical progress note documented redness and a small healing blister on the resident's front left knee. The care plan identified impaired skin integrity due to the blister and immobility. However, a review of the medical record and treatment administration record (TAR) showed no assessment or monitoring of the wound during the resident's stay. Staff confirmed that although the blister was identified during the admission assessment, monitoring was not implemented, and no further assessments were completed. Facility leadership stated that the expected protocol for skin impairments was not followed, as the blister was not documented for ongoing monitoring or alert charting.