Failure to Monitor Surgical Incision and Non-Pressure Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to assess, evaluate, and monitor non-pressure skin conditions and a surgical incision according to physician orders and facility policy for one resident. The facility’s undated Non-Pressure Injury/Ulcer Management policy required staff to identify and investigate non-pressure wounds, report changes in skin integrity including surgical wounds, conduct weekly skin observations by a licensed nurse, and document wound characteristics in the medical record. The resident was admitted with a right hip fracture and a surgical wound with staples, with hospital transfer orders directing daily or as-needed dressing changes and orthopedic discharge instructions calling for a follow-up incision check and x-rays 12–14 days after surgery. The resident’s care plan identified a right hip surgical incision and called for weekly skin observations and treatments as ordered, but there was no documentation that a follow-up orthopedic appointment was scheduled. Shower sheets used by CNAs documented multiple instances of skin issues in the resident’s groin and other areas, but these findings were not consistently followed up by nursing staff. On one shower sheet, the area between the buttocks and the groin was marked as red and chapped, and on another, the groin was documented as red; neither of these forms had a nurse’s signature. A later shower sheet showed redness on both arms, the groin, and both lower legs and did have a nurse’s signature. Despite these documented skin concerns, the Medication Administration Record and Treatment Administration Record for the month contained no entries for treatment of the surgical incision with staples or for the reddened areas identified on the shower sheets. Review of nursing skin assessment sheets and progress notes from admission through early February showed no documented assessment or monitoring of the resident’s groin redness or other identified reddened areas. When the resident was later sent to the hospital with altered mental status, hospital records documented that the surgical staples from the December surgery were still in place, with overgrown tissue and mild irritation at the incision site, and that the resident had intertrigo in skin folds with inflamed, irritated, and macerated skin. Interviews with facility staff confirmed that the process for non-pressure skin issues should have included nurse assessment, risk management initiation, provider notification, and placement of wound care orders on the TAR, and the DNS acknowledged that the required orthopedic follow-up appointment for incision check and x-rays had not been scheduled.
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