Failure to Assess and Monitor Non-Pressure Skin Discoloration
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, dementia, diabetes mellitus, and respiratory failure, who was also on hospice care and had a life expectancy of less than six months, was observed with a large dark purple discoloration on her left elbow on two separate occasions. Despite the presence of this discoloration, the resident's medical record, including the most recent weekly skin assessment, did not document any skin integrity alterations or bruising, nor was there any evidence that the discoloration had been assessed or monitored. Interviews with facility staff revealed that the LPN was unaware of the discoloration, and the Director of Nursing confirmed there was no prior documentation of assessment or monitoring for the skin issue. The facility's care plan required weekly and as-needed skin assessments, with abnormal findings to be reported to the physician, and the facility's policy mandated that any skin alterations be reported and assessed by a licensed nurse. These actions were not followed, resulting in the deficiency.