Failure to Ensure Competent Weekly Skin Assessments by Nursing Staff
Penalty
Summary
Licensed nursing staff failed to demonstrate and acknowledge the required competency skills for completing weekly skin assessments for a resident identified as high risk for pressure ulcers and with worsening skin conditions. The resident had multiple comorbidities, including stroke, aphasia, hemiplegia, malnutrition, diabetes, and was dependent on staff for mobility and personal care. Despite being at high risk for skin breakdown, documentation and interviews revealed that weekly skin assessments were incomplete, with the nurse often relying on nurse aides' observations rather than conducting a thorough visual inspection of all skin areas. The nurse admitted to not always removing the resident's clothing and not assessing all areas, particularly those covered by clothing, and was unsure of the full requirements for weekly skin assessments. The resident's medical records indicated that prior to hospital admission, there were only minimal notes about skin redness and bruising, with no detailed documentation of open wounds or significant changes. However, upon hospital admission, the resident was found to have extensive skin breakdown, including a large, necrotic, unstageable pressure wound on the sacrum, deep tissue injuries on the thigh and heel, and other lesions. Hospital staff noted that these wounds were present on admission and were of significant size and severity, suggesting they had developed over a period of weeks. Interviews with hospital staff and facility nurse practitioners confirmed that the wounds could not have developed overnight and should have been identified earlier through proper skin assessments. Further review of the nurse's education and competency records showed no evidence of recent or specific training on skin assessments. Facility policy required weekly skin inspections by licensed staff, notification of providers and family for new or worsening skin issues, and detailed documentation of findings. However, these procedures were not followed, as evidenced by the lack of comprehensive skin assessments, failure to document and report changes, and inadequate communication among staff. The deficiency had the potential to affect all residents in the facility due to the systemic nature of the competency and documentation failures.