Failure to Timely Assess and Treat Resident Rash Due to Breakdown in Communication and Policy Adherence
Penalty
Summary
The facility failed to ensure that a resident received timely assessment and treatment for a rash, as required by professional standards of practice and the facility's own change of condition policy. The resident, who had a history of stroke, moderate cognitive impairment, incontinence, and was at risk for skin breakdown, developed a rash on multiple areas of his body. Documentation shows that the rash was first noted by nursing staff, who recorded the presence of itchy, reddish areas on the resident's extremities and notified the nurse practitioner (NP) via telephone message. However, no treatment orders were obtained at that time, and there was no documentation of follow-up or monitoring instructions from the NP. Over the next two days, multiple licensed vocational nurses (LVNs) documented the ongoing presence of the rash and the resident's complaints of itchiness, but did not obtain new treatment orders or ensure that the NP was contacted again. Communication between shifts was inconsistent, with some nurses stating they had reported the rash to the next shift or to the treatment nurse, while others denied receiving such reports. The treatment nurse was not notified of the rash until she independently assessed the resident and observed the skin condition, at which point she contacted the NP and obtained orders for topical and oral medications. Interviews with staff revealed confusion and lack of clarity regarding the process for reporting and following up on changes in resident condition. The facility's policy required prompt communication of unusual signs and symptoms to the physician and documentation of all attempts to reach the physician, as well as ongoing assessment and documentation until the condition stabilized. In this case, the policy was not followed, resulting in a delay of several days before the resident received appropriate treatment for his rash.