Failure to Obtain and Follow Treatment Orders for Skin Alterations
Penalty
Summary
The facility failed to obtain a treatment order, assess, and provide appropriate care for a resident who developed a skin tear on the left knee. The resident, who had multiple diagnoses including Alzheimer's disease and required substantial assistance with activities of daily living, sustained a skin tear during physical therapy. Although an incident report documented that the physician was notified and an order was obtained to cleanse the wound and change the dressing every three days, there was no corresponding treatment order on the physician order sheet, no documentation in the treatment administration record, and no evidence of wound assessment or care in the nurses' progress notes. The dressing on the resident's knee was found to be dirty and saturated, and staff were unaware of the wound or the need for ongoing care, indicating a lack of communication and documentation regarding the resident's condition and treatment needs. Additionally, the facility failed to follow a physician's order for another resident with moisture-associated skin dermatitis. The resident had a history of incontinence-associated dermatitis and was prescribed Zinc Oxide Ointment to be applied every shift as a preventative measure. Review of the electronic treatment administration record over several months revealed multiple instances where nurse signatures were missing, indicating that the treatment may not have been administered as ordered. Staff interviews confirmed that nurses are required to document treatments in the electronic record, and the facility's policy mandates prompt identification, documentation, and treatment of skin breakdown. Both deficiencies demonstrate failures in obtaining and following physician orders, documenting care, and ensuring that residents with skin alterations receive appropriate and timely treatment. The lack of documentation and communication among staff contributed to the deficiencies in care for residents with skin integrity issues.