Failure to Implement Skin Protection and Timely Wound Care Resulting in Harm
Penalty
Summary
A resident with a history of diabetes and peripheral vascular disease, who was admitted post-amputation, was identified as high risk for skin impairment due to decreased mobility, edema, and circulatory issues. The care plan included interventions for skin issues, but when a skin tear was discovered on the resident's left foot, the intervention of heel boots was documented as a new measure. However, clinical records did not show that the heel boots were added to the care plan or implemented in a timely manner, with evidence indicating a delay of several days before the intervention was put in place. Further review revealed that after the initial skin tear, the resident developed a new open area on the left foot, which worsened over time. The wound increased in size and severity, with signs of infection such as increased redness, warmth, and drainage. Despite the identification of the wound, there was a lapse in wound care, as the wound was not treated for two days after it was first noted. Treatment was eventually initiated, but the wound continued to deteriorate, leading to a diagnosis of cellulitis and the need for antibiotic therapy. Staff interviews and documentation confirmed that the heel boot intervention was not consistently implemented, and there was no documented evidence of its use to protect the resident's feet from further skin impairment. The nursing home administrator acknowledged the lack of documentation and confirmed that wound care was not provided on specific dates. These failures resulted in actual harm to the resident, as the wound worsened and became infected.