Failure to Monitor and Communicate Resident's Spreading Rash
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident who was at risk for skin breakdown and confined to bed with a diagnosis of End-Stage Renal Disease. The resident developed a rash in multiple areas, including the bilateral breast folds, which was documented in the care plan with instructions to monitor for increased spread or signs of infection. However, the Treatment Administration Records (TARs) for the relevant months showed that the rash was not monitored as required, and there was no documentation of skin condition monitoring. Additionally, a change of condition note indicated the rash was spreading, but the resident's representative was not notified of this change. The resident's family member reported not being informed by the facility about the skin condition or the presence of a wound under the breast, only learning of it from hospital staff after the resident was transferred to the emergency department, where the wound was found to be septic. Review of facility policy confirmed that the facility was required to promptly notify the resident, physician, and representative of changes in condition, but this did not occur. The Assistant Director of Nursing confirmed that the required notifications and monitoring were not completed according to the care plan and facility policy.