Failure to Conduct Required Skin Assessment Prior to Discharge
Penalty
Summary
The facility failed to provide professional standards of care for a resident when a required skin assessment was not conducted prior to discharge. The resident, who had a history of chronic venous hypertension with ulcers on both lower extremities, lymphedema, and type 2 diabetes mellitus, was discharged without documentation of their skin condition or management. Both the Discharge Instruction Form and Discharge Summary lacked information regarding a skin assessment at the time of discharge. Interviews and record reviews revealed that the Treatment Nurse was aware of the resident's multiple venous ulcers, fragile skin, and a deep tissue injury on the left heel, which was later classified as unstageable. Despite these significant skin issues, the Unit Manager did not perform the required skin assessment before the resident left the facility, and there was no documentation explaining the missed assessment. The Director of Nursing confirmed that the facility's process for conducting a skin assessment prior to discharge was not followed in this case. The facility's policy, revised in December 2016, requires an assessment and documentation of the resident's condition, including a skin assessment, at discharge. The lack of a documented skin assessment and omission of skin condition details on discharge forms directly contributed to the deficiency identified by surveyors.