Failure to Complete Admission Skin Assessment for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive skin assessment upon admission for a female resident with multiple diagnoses, including diabetes mellitus type 2, severe obesity, and a stage 2 sacral pressure ulcer. The resident was admitted from the hospital with a documented stage 2 pressure injury, but the hospital discharge information did not include wound measurements. Upon admission, only a basic skin assessment was performed by an LPN, which noted bruising on the forearms but did not identify the sacral wound. A comprehensive skin assessment was not completed until two days after admission, at which point an RN documented the stage 2 sacral wound and its measurements. Due to the lack of an initial comprehensive assessment, there was no documentation to determine whether the pressure injury had worsened or improved since admission. The DON confirmed that a comprehensive skin assessment should have been completed upon admission, but this was not done, resulting in incomplete documentation and monitoring of the resident's pressure injury.