Failure to Timely Identify and Treat Resident Wound Resulting in Harm
Penalty
Summary
A deficiency occurred when facility staff failed to timely identify, assess, and provide treatment for a resident's right lower extremity wound. The resident, who had a history of psoriasis vulgaris and absence of the left foot, was assessed as being at risk for skin impairment and pressure ulcers. Despite care plans and physician orders requiring weekly skin assessments and daily monitoring, documentation showed that no wounds or pressure areas were identified in multiple weekly assessments, and there was a lack of evidence that staff properly assessed or documented the resident's skin condition during this period. On June 1, a nurse aide observed a closed, red area on the resident's right leg and reported it to a nurse, but the nurse later stated she was unaware of any skin concerns and did not recall being notified. Subsequent investigation revealed that three licensed nurses and one nursing assistant failed to follow facility policies regarding reporting, documentation, assessment, and provider notification for changes in skin integrity. One nurse was found to have falsified documentation, concealing evidence of negligence, while another failed to provide necessary treatment and ensure appropriate care. The wound was ultimately discovered on June 3, at which point it was found to be open with exposed bone, and the resident was transferred to the hospital with a diagnosis of wound infection and arterial insufficiency. Interviews with facility staff, including the DON, wound nurse practitioner, and CRNP, confirmed that the wound had not been identified or reported prior to June 2. The resident's hospital records indicated admission for a worsening right lower extremity wound, cellulitis, and arterial blockages. The facility's internal investigation substantiated neglect, citing failures in timely identification, assessment, and intervention for the resident's wound, which resulted in actual harm requiring hospitalization.