- Date
- 7/2/2025
- Report number
- CALMS - 00084020
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 07/10/25 and 07/11/25, the facility’s failure to evaluate the resident, refer to the facility nurse, and document the change, and update the service plan was substantiated for 1 of 1 sampled resident (#1). Findings include, but are
not limited to:
A review of Resident 1's Hospital Discharge After Visit Summary dated 07/01/25, indicated instructions for skin tear to the left shoulder: "If there is a dressing or bandage, change it when it gets wet or dirty;" "Otherwise, leave it on for the first 24 hours, then change it once a day, or as often as the healthcare provider says;" and "After three days, you can keep the bandages off the wound, unless told otherwise, or there is continued drainage; allow the wound to be open to the air."
A review of Resident 1's Progress Notes dated 07/02/25 through 07/14/25 indicated the following: On 07/02/25, Interim Service Plan was created regarding Resident 1's fall on 07/01/25, with instructions for staff to report any concerns of increased pain, bruising, or further injury to the area to the Med Tech (MT), Licensed Nurse, (LN) or Medical Doctor (MD). Frequency as needed or requested; On 07/03/25, Skin Note that LN cleaned and changed the dressing; On 07/05/25, Alert Chart indicated the Resident had pain when lying on his/her left side; 07/05/25, Alert Charting indicated the Resident had expressed a couple of complaints of pain in certain positions. No other concerns and skin tear is being followed by the nurse. Removing this alert at this time; 07/08/25, Alert Charting notes indicated Resident's skin tear was uncovered with sterile strips on it. His/her skin tear looked very infected. Staff informed LN; 07/08/25, Interim Service Plan created with instructions that the resident has a skin issue on the left side shoulder; staff to report any complaints of infections, redness, odor, swelling, drainage, or temperature above 100 degrees Fahrenheit to the MT or LN; and 07/11/25, Skin Note, late entry for 07/08/25, LN provided wound care and new dressing. LN noted white slough present to the upper area of the wound.
In an interview on 07/10/25, Staff 3 (RN) stated the following: "We have standing orders to provide wound care;" In response to being asked if the wound care was on Resident 1's MAR Staff 3 responded, "No, but I can add instruction to the MAR/TAR now;" and "Staff are not trained to provide wound care. I am monitoring it."
The resident was experiencing pain per progress notes, which was part of the instructions to monitor. There was no indication of nurse follow-up or that information was provided to the nurse or physician to treat the resident's pain. Alert Charting was removed on 07/05/25, before resolution.
It was determined that the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan.