Failure to Complete Required Skin Assessment Prior to Discharge
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to perform a required skin check on a resident prior to discharge. The resident, who had a history of type 2 diabetes mellitus and major depressive disorder, was moderately impaired in cognitive skills and required assistance with several activities of daily living. The resident's care plan specifically identified a risk for skin breakdown and required daily skin assessments and weekly body checks. On the day of discharge, the post-discharge plan of care for the resident was left incomplete, with the section for skin condition assessment left blank. The LVN signed the discharge plan of care but did not conduct the necessary skin check. This omission was contrary to both the facility's policy and the statements of other nursing staff, who confirmed that a skin check should be completed and documented prior to discharge to determine if treatment or family education was needed. After discharge, the resident's family member discovered the resident had bleeding scabs covering the body and was unaware of any skin issues prior to taking the resident home. A home health nurse assessed the resident the following day and observed a rash all over the resident's body, with the resident complaining of itching. Facility policies required assessment and documentation of skin integrity, notification of the physician, and communication with the family in cases of skin alterations, none of which were completed prior to discharge.
Plan Of Correction
F0684-Quality of Care Corrective Immediate Action: LVN1 was immediately in-serviced by the Administrator on 07-09-25 ensuring that discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge, emphasizing the resident's skin assessment. Others Affected: On 07-09-25, the Licensed Treatment Nurses did a body check on all residents and no new rashes were identified. Preventative Measures: On 07-08-25 and 7-10-25, the Quality Assurance and Staff Developer conducted an in-service training for the Licensed Nurses on focusing on the facility's policy and procedure on Discharge Summary Planning with emphasis on the following: 1. Proper completion of discharge summary records. 2. The critical importance of assessing and documenting the resident's skin condition prior to discharge, whether the resident is leaving for home, a hospital, or a lower level of care. Monitoring Performance: The Medical Records Director will review all discharge records the day after a resident has been discharged whether to home, a hospital, or a lower level. The review ensures that licensed nurses are complying with facility policies and procedures, particularly the completion of the required skin assessments. If discrepancies or issues are found during the discharge record audit, the Medical Records Director will notify the DON. The DON will then provide counseling and re-education to the licensed nurse involved, ensuring the importance of completing skin assessments and adhering to procedures is emphasized. The result of all discharge record audits will be reported to the QA Committee Monthly by the Director of Nursing for further review and follow-up recommendations, for a period of three months. Corrective Action will be accomplished on 7/10/25.