Failure to Assess and Monitor Skin Integrity for Resident with Leaf Sensor Device
Penalty
Summary
The facility failed to follow professional standards of practice in the management, assessment, and monitoring of a resident who was admitted with a Leaf Sensor medical device. The resident, who had multiple diagnoses including metabolic encephalopathy, type II diabetes mellitus, actinic keratosis, and rosacea, was admitted with a Leaf Sensor attached to the mid-chest. The care plan identified the risk of skin breakdown and infection at the sensor site, with specific interventions such as providing good skin care, assessing skin integrity, assessing for pain, and reinforcing the sensor with Tegaderm if dislodged. However, there was no documentation that these interventions were carried out, particularly regarding assessment of skin integrity and pain at the sensor site. Interviews with facility staff revealed a lack of knowledge and training regarding the Leaf Sensor device. The Certified Nursing Assistant reported not being informed about the care required for the sensor, and the Treatment Nurse admitted to never fully assessing the skin underneath the device or being educated on its use. The Director of Nursing confirmed that there was no specific policy for the device and that the manufacturer's guidelines were not fully implemented, as the sensor was never removed or the skin underneath assessed during the resident's stay. Additionally, the monitoring component of the device was not present in the facility, and there was no documentation of reinforcement or assessment as required by the care plan and physician's orders. The facility's policies required licensed nurses to document meaningful and informative notes reflecting care, treatment, and assessments, including skin and pain assessments. The manufacturer's guidelines for the Leaf Sensor also specified the need for periodic inspection of the skin around the sensor for signs of irritation or infection. Despite these requirements, the facility did not document or perform the necessary assessments, placing the resident at risk for skin-related complications associated with the device.