Failure to Monitor Skin Condition, Follow Up on Change in Condition, and Maintain Accurate Skin Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with professional standards for one resident with COPD, generalized muscle weakness, and moderate cognitive impairment who was dependent on staff for ADLs and mobility. On a change in condition (COC) dated 1/2/2026, the resident was noted to have redness on the left dorsal hand during treatment, and the resident reported that the blood pressure cuff on the wrist was too tight. The physician ordered monitoring of the left dorsal hand discoloration for hematoma formation, skin breakdown, and pain/discomfort, with instructions to document "Y" if observed and notify the MD, or "N" if not observed, on every shift for 30 days. Review of the Treatment Administration Record (TAR) and progress notes for January 2026 showed no documentation of the required Y/N monitoring or any indication that the left dorsal hand was monitored as ordered. A second deficiency occurred on 1/20/2026 when the resident experienced a change in condition involving self-inflicted lacerations to both lower legs. The COC note documented that staff were awaiting the MD’s response. However, review of the resident’s progress notes for that date did not show any follow-up with the MD for treatment orders for the bilateral lower leg wounds. Interviews with nursing staff indicated that if staff were unable to reach the MD, they should attempt to contact the MD’s nurse practitioner or the facility’s Medical Director, and if still unsuccessful, endorse the issue to the oncoming shift, but such follow-up and documentation were not evident in the record. The DON confirmed that the progress notes did not show that staff had followed up with the MD after this change in condition. A third deficiency involved inaccurate and late skin assessment documentation by the Treatment LVN. Weekly skin checks dated 1/4/2026, 1/9/2026, 1/16/2026, and 1/23/2026 did not include the status or description of the left dorsal hand redness. The Treatment LVN stated she could not explain why the left hand status was not documented and acknowledged that on 1/23/2026 she changed her skin check notes to "ecchymosis" to match the wound MD’s assessment from that date, even though this was not her original assessment, making the documentation inaccurate. On 1/27/2026, the Treatment LVN created another skin check form with an effective date of 1/2/2026 to reflect the redness that had been present on 1/2/2026 but not documented at that time, and she acknowledged that charting 25 days after the assessment made the documentation inaccurate. Facility policies required entries to be written promptly in chronological sequence, weekly skin evaluations with documentation of treatments and effectiveness, and detailed documentation of MD notification for changes in condition, including time, method, response time, and whether orders were received, which were not followed in these instances.
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