Failure to Complete Physician-Ordered Skin Care Treatment
Penalty
Summary
The facility failed to ensure that a resident's skin care was completed as ordered by the physician. The resident, who had a history of paralysis, bipolar disorder, depression, muscle weakness, insomnia, and respiratory failure, was cognitively intact and required varying levels of assistance for daily activities. The care plan identified an alteration in skin integrity, specifically a rash on the left inner thigh/groin area, with interventions including assessment and treatment per physician's orders. The physician ordered cleansing of the affected area and application of miconazole powder every shift. Review of the treatment administration record (TAR) showed that the ordered treatment was not documented as completed on multiple day shifts. During interviews, the resident reported inconsistent application of the powder, and observation confirmed the presence of a large, red area on the left thigh. Nursing staff acknowledged responsibility for applying treatments, and the DON could not provide evidence that the treatment was completed as ordered. Facility policy required necessary treatment and documentation for skin integrity issues, but this was not followed in this case.