Failure to Assess and Monitor Change in Skin Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident who developed a rash on both hands. According to the facility's policy, any change in a resident's condition, such as a new skin issue, requires a licensed nurse to perform and document an assessment, notify the physician and responsible party, and monitor and document the resident's condition for at least three days. In this case, a physician ordered miconazole nitrate cream to be applied to the resident's hands for the rash, but there was no documented evidence that a change of condition assessment or required monitoring was completed. Interviews with nursing staff confirmed that the assessment and documentation were not performed as required by policy. The resident involved was cognitively intact and able to make decisions, as indicated by a BIMS score of 13 and a recent history and physical examination. Despite the new order for antifungal treatment, the medical record lacked documentation of assessment, monitoring, or care plan updates related to the rash. Nursing staff acknowledged the omission, and the DON confirmed awareness of the findings during the survey.