Failure to Provide Timely Wound Care and Skin Assessments
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 resident was admitted with a superficial abrasion on the right heel, but there were no physician orders in place to treat or monitor the heel abrasion from the time of admission through several weeks. Despite an order for a wound consult and a pressure-relieving mattress, there was no documentation of wound care being performed, and no wound consult notes were found in the resident's chart. The care plan identified a risk for impaired skin integrity, but interventions were not implemented or documented as required. Weekly skin assessments were not completed as scheduled, with missed assessments on two specific dates. Nursing staff interviews revealed confusion and lack of clarity regarding responsibility for skin assessments and reporting of skin changes. One RN was unable to access the electronic charting system and did not complete or document all required skin assessments, nor did she escalate the issue to facility management or corporate staff. Other staff members observed changes in the resident's heel, such as blistering and discoloration, and reported these to nurses, but there was no evidence that these reports led to timely physician notification or initiation of treatment orders. Multiple staff interviews confirmed that changes in the resident's skin condition were not consistently reported to the appropriate clinical leadership, such as the DON, ADM, or physician. The facility lacked a DON at the time, and staff were unclear about the reporting chain. Observations of the resident's heel showed progression from an abrasion to areas suggestive of pressure injury and possible necrosis, yet no wound care or monitoring was documented. Facility policy required full assessment and documentation of pressure ulcers and prompt physician notification, but these standards were not met in this case.