Failure to Assess Resident's Skin Leads to Infected Wound from Embedded Bracelets
Penalty
Summary
Licensed nursing staff failed to perform a full body skin assessment on a resident who had a history of mild intellectual disabilities and moderate cognitive impairment. The resident required partial to moderate assistance with activities of daily living and had no documented skin conditions prior to the incident. On one occasion, a Licensed Vocational Nurse (LVN) noticed a foul odor coming from the resident but did not identify its source, did not conduct a full body assessment, and did not notify a supervisor or Registered Nurse (RN) about the issue. The following day, the LVN again noticed the odor and informed the RN, who instructed the LVN to provide the resident with another shower, despite the resident having already received one the previous day. Neither the LVN nor the RN performed a full body skin assessment as required by facility policy, which mandates such assessments after a change in condition or when a new wound is identified. The facility's Director of Nursing confirmed that the staff did not follow the established policy for skin assessments. Emergency medical services were called, and upon their arrival, EMTs discovered that the resident had bracelets, including a hospital band and beaded bracelets, embedded in the left wrist, causing a wound that was infected and emitting a strong odor. The bracelets were removed by the EMTs, and the wound was noted to be infected with discharge. The failure of the nursing staff to assess the resident's skin and identify the embedded bracelets led to the development of the infected wound.
Plan Of Correction
F 684 Quality of Care CFR(s): 483.25 Resident 1 was re-admitted back to our facility on 3/28/25. He was assessed by the RN supervisor on 3/28/25. Left wrist noted with dry scab with no signs of infection. RN1 and LVN 1 were given a one-on-one in-service and 1:1 Skills and Policy review by the DON on 4/11/25. Disciplinary action was given by the DON to the RN1, LVN1, and the CNAs who were assigned to Resident 1. DON, RN/LVN supervisors performed body/skin checks to the current residents on census as of 4/10/25 to identify any residents affected with the findings. Skin/Body checks were completed on 4/30/25. No other residents were affected. DON in-serviced licensed nurses on 4/9/25, 4/11/25, and 4/28/25 regarding Skin assessment Policy upon admission/readmission, change of condition, and as needed. DSD in-serviced CNAs on 4/9/25 regarding skin and body assessment including reporting to licensed nurses for any changes. A follow-up in-service to CNAs, LVNs, and RNs was given on 4/25/25 by the DSD. To monitor compliance, the DON and/or Designee will conduct random skin assessment reviews to licensed nurses on a weekly basis. Any issues will be addressed and corrected immediately. Findings will be reported by the DON during quarterly QA&A meetings for 6 months.