Failure to Care Plan for Resident with Documented Dry Skin
Penalty
Summary
Surveyors identified that the facility failed to develop and implement an individualized, person-centered care plan for a resident who was admitted with documented dry skin to the face and bilateral lower extremities. The resident’s admission assessment, completed in the evening on the date of admission, recorded excessive dry skin under the body check section. Despite this documented skin abnormality, a review of the resident’s care plans showed there was no care plan addressing dry skin. The facility’s Assistant Director of Nursing (ADON) stated in interview that dry skin is considered a skin abnormality that must be care planned and confirmed that the resident was admitted with dry skin to the face and both legs but had no corresponding care plan. The resident’s medical record indicated admission with diagnoses including sequelae of cerebral infarction, diabetes mellitus, and heart failure. The Director of Nursing (DON) stated that not accurately assessing the resident’s dry skin could have resulted in broken skin or infection. Review of the facility’s policy and procedure titled “CARE PLAN COMPREHENSIVE” showed that the Interdisciplinary Team, in coordination with the resident and/or representative, is required to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes to meet identified needs from the comprehensive assessment, including incorporation of identified problem areas and associated risk factors. The failure to create a care plan for the resident’s dry skin was inconsistent with this policy and represented the cited deficiency.
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