Failure to Adequately Assess and Treat Resident Skin Conditions
Penalty
Summary
The facility failed to ensure that a resident's skin was adequately assessed and treated according to professional standards and facility policy. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, obesity, and recent orthopedic aftercare, was identified as high risk for skin breakdown. The care plan required weekly skin checks and treatment as ordered, but there was no evidence of a physician's order for weekly skin checks, and documentation of these assessments was inconsistent or missing. Multiple skin issues were documented by CNAs on shower sheets, including a popped blister on the sacral region, blisters on the chest, red spots on the abdomen, and bruising on the arm. Despite these findings, there was no evidence that nurses completed further skin assessments, notified providers, or obtained new treatment orders for the newly identified skin conditions. The clinical record lacked documentation of follow-up assessments or interventions for these issues, and scheduled skin assessments were missed without follow-up. Interviews with staff confirmed that the expected process was for CNAs to report new skin findings to nurses, who would then assess, notify providers, and document actions taken. The Director of Nursing acknowledged that the required weekly skin assessment was not completed and that there was no documentation or follow-up on new skin issues identified by CNAs. The facility's policy required comprehensive skin assessments on admission and weekly thereafter, but these procedures were not consistently followed for this resident.