Failure to Identify and Document Resident Wounds and Pain Complaints
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for a resident who reported significant pain and had undocumented wounds. Over a period of months, the resident stated he experienced severe burning pain with urination and significant leg pain, and reported these concerns to multiple staff members. On observation, the resident’s lower legs were discolored with open wounds and scabbing on both legs. However, multiple weekly skin assessments documented no skin impairments and did not identify any wounds on the lower legs. The ADON, who completed a skin assessment on one of those dates, confirmed she did not document any wounds and did not recall seeing any at that time, and another LPN who usually performed the resident’s skin assessments reported awareness only of a wound on the resident’s hand, not the legs. Interviews revealed that some staff were aware of the leg wounds but did not ensure they were assessed or documented, nor was there documentation that the provider or DON were notified. The DON confirmed she had not been made aware of the leg wounds until the surveyor observation. Additionally, although the resident repeatedly complained of burning with urination, there was no documentation in the medical record of these complaints, no record that the provider was notified, and no evidence of follow-up. One LPN acknowledged that the resident told her it was “burning down there,” but she was confused about the location of the pain, was unsure if she notified the provider, and did not document the complaint. The resident continued to report leg pain and burning with urination during interviews with the surveyor and ADON.
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