Failure to Obtain and Document Provider Orders for Skin Tear Treatment and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a provider’s order for treatment and ongoing monitoring of a skin tear. A male resident with diagnoses including end stage renal disease, type II diabetes, and epilepsy, and a BIMS score of 11 indicating moderately impaired cognition, was admitted with a care plan identifying risk for impaired skin integrity. A skin issue risk assessment documented that the resident sustained a skin tear to the right forearm when his arm became caught between two bathroom rails near the toilet. The RN cleansed the wound with normal saline and applied three steri-strips, and documented that the NP was notified, but there was no documentation of any provider order for the treatment or for monitoring the wound until healed. Review of the resident’s discontinued and current physician orders and the TAR for the relevant month showed no orders for treatment or daily monitoring of the right forearm skin tear and no documentation that treatments or monitoring were performed. On interview, the resident did not recall how the injury occurred, and the wound appeared to be healing without signs of infection. The RN stated she notified the POA, NP, and administration, and that the NP indicated the treatment she provided was appropriate, but she did not document any order or obtain an order for ongoing monitoring, believing it was a one-time, common-sense dressing. The NP confirmed she had been contacted and agreed the initial treatment was appropriate, but stated the treatment and daily monitoring should have been entered as provider orders in the electronic health record. The DON stated her expectation that such orders be documented and placed on the TAR for daily reminders, and the facility’s skin policy required notifying the healthcare provider for further treatment orders when a new wound is identified.
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