Failure to Assess and Monitor Skin Integrity Resulting in Neglect
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes mellitus type II and hemiplegia was not properly assessed or monitored for skin integrity, despite being at increased risk for pressure ulcers. Upon admission, the resident had no documented skin issues, and a quarterly assessment confirmed no skin concerns while indicating a Braden score of 16, which placed the resident at increased risk for pressure injury development. However, there was no documentation of weekly skin assessments or monitoring between late January and early February, and no evidence that the resident received treatment for pressure ulcers or injuries during this period. The facility's policies required regular skin assessments and prompt reporting of any changes in skin integrity, but these procedures were not followed. Certified Nursing Assistant (CNA) documentation did not indicate any skin issues, and there was no record of staff conducting or documenting the required weekly skin assessments. Additionally, there was no documentation of wound care or physician notification regarding any skin breakdown prior to the resident's transfer to the hospital. When the resident was transferred to the hospital for altered mental status and slurred speech, a hospital wound consult identified multiple unstageable pressure injuries and a deep tissue injury that had not been previously documented by the facility. Interviews with facility staff confirmed that no wounds were documented prior to the resident's readmission, and no inservices had been conducted to address the lack of skin assessments. This failure to assess, monitor, and document the resident's skin condition resulted in neglect and a deficiency related to the resident's right to be free from neglect.