Failure to Perform Required Weekly Skin Assessments for Resident with Wound
Penalty
Summary
The facility failed to ensure that a resident's open area on the right buttock was comprehensively assessed, specifically omitting weekly skin assessments that are required for residents with wounds. The resident, who was admitted with diagnoses including Huntington disease and anemia and was noted to be severely impaired in thought process, developed a skin wound or ulcer. Documentation from a Change of Condition evaluation indicated the presence of an open area on the right buttock without signs of infection, but there was no evidence of ongoing weekly skin assessments to monitor the wound's size or healing progress. During interviews, both a Licensed Vocational Nurse and the Director of Nursing confirmed that weekly skin assessments were not performed as required by facility policy for residents with wounds. The facility's policy mandates a full assessment of pressure sores, including documentation of location, stage, size, exudate, pain, mobility status, current treatments, and active diagnoses. The absence of these assessments meant the resident's wound progress was not properly monitored or documented.