Failure to Assess, Monitor, and Document Skin and Wound Care
Penalty
Summary
The facility failed to properly assess, monitor, document, and provide treatment for a resident with significant skin and wound care needs. The resident, who had diagnoses including diabetes, edema, and hypertension, was admitted with bilateral lower extremity edema and was at risk for skin integrity issues. Despite care plan interventions requiring regular assessment and documentation of edema and skin condition, there were lapses in following these protocols. Notably, the resident developed worsening edema, with observations of weeping fluid and open areas on the lower legs, but documentation and assessment were inconsistent. Orders were in place for daily weights to monitor edema and for specific wound care treatments, including cleansing and dressing changes. However, records revealed that daily weights were not documented after the order was written, and there was no evidence that weekly skin assessments were completed as scheduled. The treatment administration record did not reflect the daily weights order, and a required skin assessment was missed on the resident's assigned day. Additionally, when an open area developed on the resident's shin, there was no wound assessment documented in the medical record as required by facility policy. Interviews with nursing staff and the DON confirmed that documentation and assessments were not completed according to policy and physician orders. The facility's own policy required regular skin inspections, prompt reporting of abnormal findings, and communication among team members, but these procedures were not consistently followed for this resident. These failures resulted in a lack of timely assessment, monitoring, and documentation for the resident's skin and wound care needs.