Failure to Complete Required Skin Assessments After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, after two separate hospitalizations, there was no documentation that a full body skin assessment was completed upon the resident's return, as required by the facility's own policy. The policy mandates that a licensed or registered nurse perform a full body skin assessment upon admission or readmission, daily for three days, and weekly thereafter. Despite this, there were no skin or wound assessments documented for the dates the resident returned from the hospital. The resident involved had multiple risk factors, including type 2 diabetes with polyneuropathy, chronic venous hypertension with ulcer, and a history of pressure ulcers. The resident's Braden Scale scores fluctuated between high and mild risk for pressure ulcers. Progress notes and wound visit reports confirm that wound assessments were not performed or documented on the days the resident returned from the hospital, and staff interviews confirmed that assessments were expected but not completed. Direct observation of the resident's wound revealed significant changes in the wound's size and appearance, further underscoring the lack of timely assessment.