Failure to Document and Report Skin Openings on Admission
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not thoroughly document measurements of two skin openings on the resident's bilateral buttocks and did not notify the physician or nurse practitioner regarding these skin openings, which were present upon admission. Weekly skin assessments from admission through the end of the month documented the same information repeatedly, noting moisture-associated skin damage and redness, but did not identify or measure the open areas. Nursing progress notes during this period also lacked documentation regarding skin integrity or notification to the medical provider or family about the skin issues. Upon observation, the resident reported soreness on his bottom and expressed a desire for more care regarding this issue. Physical examination revealed a small circular skin opening on one buttock and a small slit on the other. The weekly skin assessment and nursing progress notes were only updated to reflect these findings after surveyor intervention. Prior to this, there were no physician orders addressing impaired skin integrity, and the treatment nurse (ADON) was not aware of the skin openings. Interviews with nursing staff confirmed that the expectation was to measure and document any skin openings and notify the treatment nurse and medical provider, but this process was not followed for this resident. Facility policies and in-service training required a head-to-toe skin assessment upon admission, documentation of all skin issues, initiation of treatment orders, and notification of the physician and responsible party. These procedures were not followed in this case, as the skin openings were neither measured nor reported to the appropriate medical personnel until prompted by the surveyor. The failure to adhere to these protocols resulted in a lack of timely and appropriate care for the resident's skin condition.