Failure to Timely Assess, Document, and Treat Skin Injuries Resulting in Hospitalization
Penalty
Summary
The facility failed to provide quality care in the prevention and management of skin injuries for a resident with significant medical complexities, including chronic heart failure, peripheral vascular disease, malnutrition, and Brown-Sequard syndrome. The resident was dependent on staff for repositioning and transfers, and had a history of pressure ulcers, including an unstageable ulcer on the coccyx. Despite having a care plan and physician orders in place for regular skin assessments and wound care, staff did not consistently evaluate, document, or communicate changes in the resident's skin condition, particularly regarding new wounds on the left lower leg, left foot, and right lower leg. Multiple breakdowns in communication and documentation were identified. When new wounds were first observed, the responsible nurse did not complete a skin evaluation or document the findings, and there was confusion regarding the correct location of the wounds in communications with the physician. Treatment orders were delayed and not implemented promptly, and there were several days where no interventions were provided for the resident's leg wounds. Staff interviews revealed uncertainty about documentation procedures and a reliance on the wound care nurse to address new skin issues, rather than immediate action by the nurse who identified the problem. The lack of timely assessment, accurate documentation, and prompt intervention resulted in the resident's wounds worsening, ultimately requiring hospitalization. The facility's own policies required daily skin inspections, prompt reporting of changes, and immediate implementation of interventions for new or worsening wounds, but these procedures were not followed. The failures in evaluation, communication, and treatment placed the resident at risk for serious harm and led to the identification of an Immediate Jeopardy situation by surveyors.