Failure to Document Urine Output and Timely Assess Skin Breakdown
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and the resident's needs for one resident. Specifically, staff did not document or record urine output as ordered by the physician for a resident with an indwelling catheter. Review of the medical record, Medication Administration Record (MAR), and Treatment Administration Record (TAR) showed no documentation of urinary output, and this was confirmed by the Regional Director of Clinical Services. The physician order required urine output to be recorded every shift, but this was not done. Additionally, the facility failed to timely assess and treat new areas of skin breakdown for the same resident. Observations revealed multiple open wounds and areas of redness and scabbing in the peri area, buttocks, thigh, and coccyx, which had been present for over a week. Certified Nursing Assistants (CNAs) reported the wounds but there was no documentation or treatment orders for these wounds in the medical record. The Wound Care Nurse was unaware of the new wounds and confirmed there were no treatment orders or documentation for them. The resident was severely cognitively impaired, dependent on staff for care, and had a history of resolved wounds, but the new wounds were not assessed or treated in a timely manner.