Failure to Prevent Pressure Injury Due to Inconsistent Skin Assessments
Penalty
Summary
A deficiency occurred when a resident, who was at risk for pressure injuries due to conditions such as dementia, diabetes, incontinence, and limited mobility, developed a deep tissue injury (DTI) to her right heel. The resident's care plan required skin assessment and inspection every shift, with particular attention to the heels, but this was not consistently implemented. The facility's policy also required daily skin inspections during personal care and weekly risk assessments, but these were not reliably performed. Nursing staff interviews revealed that skin assessments were primarily the responsibility of the treatment nurse, and when the facility was without a treatment nurse, other nurses did not assume this responsibility. Several staff members, including RNs and LVNs, stated they had not recently assessed the resident's feet or performed skin assessments, despite the care plan's requirements. The DON confirmed that skin assessments should be performed on admission and weekly, and that if a care plan called for assessments every shift, this should be done, but was unaware of any such care plans being in place. Documentation showed that the resident had no skin issues noted in assessments prior to the discovery of the DTI. The injury was first identified by an RN who noticed a dark area with surrounding redness on the resident's right heel and subsequently notified the physician and responsible party. Observations at the hospital confirmed the presence of a DTI on the right heel. The facility's failure to ensure consistent skin assessments and adherence to the care plan led to the development of the pressure injury.