Failure to Complete Weekly Skin Assessments for Resident with MASD
Penalty
Summary
A resident was admitted to the facility with Moisture-Associated Skin Damage (MASD) to the buttocks extending to the groin area, along with diagnoses of diabetes and anemia. The resident was identified as being at high risk for pressure injury, required partial to moderate assistance with toileting and personal hygiene, and was frequently incontinent of urine with occasional bowel incontinence. The care plan for the resident included monitoring and documenting the location, size, and treatment of the skin injury, as well as reporting abnormalities, failure to heal, and signs of infection to the physician. Facility policy required weekly skin assessments for residents at risk of pressure injuries. Despite these requirements, the resident did not receive a weekly skin assessment for the MASD from admission through the review period. Both the Director of Nursing (DON) and the Treatment Nurse (TN) confirmed that the weekly assessment was missed, and the electronic health record showed no documentation of such assessments. The facility's policy and procedure on prevention of pressure injuries specifically called for weekly risk assessments and ongoing evaluation of interventions, which was not followed in this case.