Failure to Assess and Monitor Non-Pressure Skin Injuries
Penalty
Summary
The facility failed to assess and monitor non-pressure related skin injuries for a resident with multiple complex medical conditions, including multiple sclerosis, diabetes, congestive heart failure, and pyoderma gangrenosum. The resident was admitted with several lesions and had a history of moisture-associated skin damage (MASD). Despite ongoing treatment orders and a care plan identifying the need for monitoring and interventions, the facility did not conduct or document weekly comprehensive wound assessments for the resident's multiple wounds. There was also no evidence of monitoring for changes in the wounds or notification to the physician when the resident refused dressing changes on two occasions. Interviews with nursing assistants revealed that they were aware of the resident's bandages but had never seen the wounds themselves, indicating a lack of direct observation or assessment by staff other than the nurse performing dressing changes. The LPN and DON confirmed that weekly comprehensive wound assessments, including measurements and evaluation of wound characteristics, were not being performed as required. The DON was unable to explain how staff would identify changes in the wounds without these assessments and was also unsure of the last dermatology follow-up for the resident. The facility's updated skin integrity policy no longer required weekly comprehensive assessments for non-pressure wounds, which contributed to the lack of ongoing monitoring and documentation. The resident's record lacked evidence of wound care follow-up as ordered by the hospital and did not include documentation of wound progress, measurements, or physician notifications for stagnant or worsening wounds. This failure to consistently assess and monitor the resident's non-pressure related skin injuries until resolution resulted in a deficiency in the facility's quality of care.