Failure to Provide and Accurately Document Non-Pressure Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered non-pressure skin treatments and accurate documentation for two residents with significant cognitive and functional impairments. One resident, admitted with diagnoses including type II diabetes mellitus, morbid obesity, dementia, and rheumatoid arthritis, had a care plan identifying risk for red and/or open skin areas with interventions to follow facility protocols and monitor and document skin injuries. A progress note documented that this resident developed two open areas on the right gluteal fold, but from the date of discovery through several days afterward there were no corresponding physician treatment orders or treatments documented on the Treatment Administration Record (TAR) for these gluteal fold wounds. Subsequently, a weekly wound observation tool entry described an abrasion on the back of the right thigh, with measurements, assessment, and a treatment order to cleanse with normal saline and apply zinc barrier cream every shift and as needed. This order and documentation were entered under the right thigh rather than the right gluteal fold, and the medical record continued to lack a specific treatment order for the two open areas on the right gluteal fold. A later weekly wound observation tool entry indicated that a gluteal fold skin alteration acquired on the earlier date was healed, but did not specify the exact location or type of alteration. The ADON confirmed that the area discovered on the earlier date was on the right gluteal fold, that no treatment was ordered until several days later, that the site was incorrectly documented as the back right thigh for assessment and treatment, and that the healed-out documentation was completed on paper without a specific healed-out note for the skin alteration. The second resident, admitted with diagnoses including type II diabetes mellitus, dementia, and age-related osteoporosis, had a resolved care plan for three skin tears on the right anterior leg with an intervention to treat per facility protocol. Progress notes documented three skin tears with a treatment order obtained, and an initial physician order directed nightly cleansing of the right anterior leg skin tears with saline, patting dry, maintaining steri-strips daily, and using an abdominal pad and kerlix as needed. A subsequent physician order changed treatment for the right lower extremity skin tears to cleansing with normal saline and leaving open to air unless drainage was noted, but the original order was not clarified or discontinued, resulting in two concurrent treatment orders being carried out on the TAR. A wound care APRN later documented a new daily (and as needed) treatment order for the right anterior lower extremity skin tears without specifying treatment details, and no addendum or clarification was found. The TAR showed that both earlier treatment orders continued to be completed through the following weeks, and documentation reflected ongoing treatment even after the skin tear area had healed. A regional nurse confirmed that the initial order was not appropriate for skin tears, that two orders were active throughout the month, and that treatment continued after healing without clarification of the incomplete APRN order.
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