Failure to Provide Accurate Skin Assessments and Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the Treatment Nurse did not document accurate skin assessments for the resident, and the resident was not provided treatment for a wound on the right great toe. The resident had multiple diagnoses, including dementia, major depression, chronic heart failure, chronic kidney disease, and high blood pressure, and required maximal assistance for most activities of daily living. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and no pressure ulcers or other skin conditions at the time of admission. The resident's care plan identified actual impairment to skin integrity, including a non-pressure area on the right great toe and a stage 2 intact blister on the top of the right foot, with interventions to provide treatment per orders. However, review of the order summary and skin assessments revealed inconsistencies and omissions. The Treatment Nurse's skin assessment documented the skin as intact, while another nurse's assessment on the same day noted a blister and scabbed areas on the toes. The wound evaluation documented a non-pressure wound on the right great toe with specific treatment orders, but these were not reflected in the order summary or implemented by the Treatment Nurse. Interviews with the Treatment Nurse, DON, ADON, and Administrator confirmed that the skin assessment was incomplete and did not include all areas of concern. The Treatment Nurse admitted to not performing a full assessment and not updating the care plan or entering necessary orders for wound care. Facility policy required a head-to-toe skin assessment for new admissions and weekly assessments for all residents, but this was not followed, resulting in the resident not receiving appropriate wound care.