Failure to Assess and Respond to Resident's Change in Condition
Penalty
Summary
Licensed nursing staff failed to properly assess and respond to a foul odor detected from a resident on two consecutive days. An LVN assigned to the resident noticed a foul smell but did not perform a full body assessment, citing it as outside their scope of practice, nor did they notify a supervisor or RN on the first day. The following day, after the smell persisted, the LVN informed an RN, who instructed the LVN to give the resident another shower, despite the LVN's report that a shower had already been given and the odor remained. The resident in question had a history of mild intellectual disabilities and mobility issues, and required varying levels of assistance with daily activities. The resident's most recent assessment did not indicate any skin conditions. However, when the resident was later evaluated at a hospital, a rubber band embedded in the left wrist was found to be infected, which had gone unnoticed and untreated by facility staff. Facility policy required licensed or registered nurses to perform full body skin assessments upon admission, readmission, and as needed, including after a change in condition or the identification of new skin issues. The Director of Nursing confirmed that LVNs are expected to report unusual findings to RNs for further assessment, but was unaware of the wound until the resident was transferred to the hospital. The failure of both the LVN and RN to assess the resident's skin condition and follow facility policy led to the deficiency.
Plan Of Correction
Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c) 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 regarding Skin assessment Policy. 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. Monthly, Skin assessment in-service will be given by the DON and DSD to licensed nurses and CNAs. 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. Skills competency training and evaluation by return demonstration will be done annually and as needed by the DON and/or designee and DSD to the licensed nurses and CNAs. Findings will be reported by the DON during quarterly QA&A meetings for 6 months.