Failure to Provide Wound Care and Neurological Assessments per Policy
Penalty
Summary
The facility failed to ensure that a resident with diabetes received daily foot checks as required by the care plan and facility policy. Despite the care plan specifying daily inspections for open areas, sores, pressure areas, blisters, edema, or redness, there was no documentation in the Treatment Administration Record (TAR) or CNA Kardex that these checks were being completed. Interviews with nursing staff and the Director of Nursing (DON) revealed confusion regarding the frequency of foot checks, with some staff believing they should be performed weekly rather than daily. Additionally, there was no physician order for daily foot checks, and the facility did not provide evidence that the checks were performed as required. The same resident developed a right heel wound, which the wound physician identified as a diabetic wound, while facility staff documented it as an unstageable pressure injury. The wound physician ordered a specific treatment for the wound, but this order was not entered into the resident's electronic medical record, and there was no documentation that the treatment was implemented or that wound care was provided after the initial assessment. Furthermore, the facility failed to conduct and document weekly wound assessments and measurements as required by policy, particularly when the resident was absent from the facility during scheduled wound rounds due to dialysis appointments. Despite a plan for the wound nurse or DON to assess the wound if the wound physician was unavailable, no such assessments were documented after the wound's initial identification. In a separate incident, another resident who experienced multiple unwitnessed falls did not receive thorough and complete neurological checks as required by facility policy. The neurological flow sheets for these incidents contained multiple missing entries for key assessment parameters such as level of consciousness, speech, pupil reaction, and hand grasps. The facility's policy outlined a specific schedule and required documentation for neurological assessments following unwitnessed falls, but these were not consistently followed or recorded. Interviews with the DON confirmed the expectation that neurological assessments should be completed after each unwitnessed fall, yet the documentation provided was incomplete.