Failure to Monitor Post-Fall Injuries, Obtain Wound Orders, and Update Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing monitoring and assessment after a resident experienced a fall with injuries, to obtain a physician’s order for treatment of a skin tear, and to develop a care plan addressing the fall and related injuries. A resident with a history of falls and bone density disorders was admitted with fragile skin and had an existing care plan indicating a potential for skin tears, with instructions to treat per facility protocol and notify the MD and family if a skin tear occurred. On the date of the incident, documentation showed the resident sustained a fall in the bathroom, with a posterior head injury described as mild erythema and a raised lump, and a right arm skin tear with a partially attached skin flap, exposed dermis, and moderate drainage. A change of condition/INTERACT assessment documented a fall, right elbow discoloration, and pain rated 7/10, and a pain assessment noted pain to the right arm related to the skin tear and to the posterior head. Progress notes from the incident described the resident found on the bathroom floor on her right side, with her head resting on the bathtub, a right arm skin tear, and complaints of back and head pain. A subsequent skin/wound note documented dark maroon ecchymosis with a scab on the right upper extremity, consistent with the recent fall, and ongoing pain to the affected extremity. Despite these findings, there was no documented evidence that the right upper arm skin tear, right elbow discoloration, or back-of-head raised areas and erythema were monitored or reassessed after the initial change in condition. The DON stated that the facility process required the licensed nurse to complete change-of-condition documentation, update care plans, and monitor neurological status, pain, and skin status every shift for 72 hours, but confirmed that this monitoring did not occur for this resident’s head and right arm injuries. Record review further showed there was no documented wound treatment order for the right arm skin tear, despite the open wound with exposed dermis and moderate drainage. Additionally, there was no updated care plan developed to address the unwitnessed fall, the right upper arm skin tear, right elbow discoloration, back-of-head raised areas/erythema, or risk for bleeding following the change in condition. Facility policies required nurses to assess and document recent injuries, especially head injuries, and to follow up on any fall with associated injury until the resident was stable and delayed complications were ruled out, as well as to revise care plans when there was a significant change in the resident’s condition. The lack of ongoing monitoring, absence of a physician order for wound treatment, and failure to update the care plan following the fall and injuries constituted the identified deficiency.
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