Failure to Document and Assess Resident's Skin Condition
Penalty
Summary
The facility failed to ensure proper documentation and assessment of a resident's skin condition, specifically regarding a rash in the perineal area. The resident, who had a history of hemiplegia, congestive heart failure, diabetes mellitus, atrial fibrillation, and gastrointestinal diseases, was admitted with intact skin and no noted pressure injuries. However, the medical record contained no evidence of skin concerns in the perineal area, despite later hospital documentation indicating the presence of a perineal rash. Statements from a CNA revealed that she observed a white rash, and later a white and pinkish-red rash, in the resident's perineal area on two separate occasions. Each time, she reported her findings to different LPNs, who provided cream for application but did not document the skin issue or notify a physician. Interviews with the involved LPNs showed a lack of recall or recognition of any significant skin issues, and no documentation was found regarding the reported rash. The DON confirmed that there was no documentation of skin issues in the resident's record and stated that nurses were expected to assess and document any reported changes. The Executive Director also stated that nurses were expected to document their responses to CNA reports. The lack of documentation and follow-up on the reported skin condition led to the deficiency.