Failure to Address Skin Discoloration and Repeated Therapy Refusals as Changes in Condition
Penalty
Summary
The facility failed to implement its policy on Changes in Residents Condition or Status for a resident admitted with multiple diagnoses, including type 2 diabetes mellitus, difficulty in walking, and muscle weakness. On the admission skin assessment, the Wound Care Nurse documented discolorations on the resident’s lower back. However, there was no documentation in the clinical record that this discoloration was further assessed, monitored, or addressed. The Wound Care Nurse acknowledged that no change of condition monitoring was done, no care plan was initiated, and the skin condition was not assessed or documented prior to the resident’s transfer out of the facility. The DON stated that the discoloration should have triggered a change of condition notification to the primary physician and responsible party on admission, and that it should have been monitored and documented according to facility policy. The facility also did not follow its policy regarding refusals of treatment. The resident had a physician’s order for Physical Therapy evaluation and treatment, and Physical Therapy notes showed that the resident refused to ambulate on four documented occasions. There was no evidence in the clinical record that these repeated refusals were addressed by the facility. The Physical Therapist stated that the resident often refused to get out of bed and walk with a walker on more than two occasions and that these refusals were only documented in therapy notes without notifying the licensed nurse. The DON stated that the resident’s refusal to get out of bed should have been communicated to the licensed nurse and that a care plan should have been initiated after more than two refusals, consistent with the facility’s policy requiring physician notification and care plan review or revision for significant changes in condition and repeated refusals of treatment.
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