Failure to Develop Baseline Care Plan for Skin Integrity Upon Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline care plan addressing skin integrity within 48 hours of admission for a resident with multiple skin conditions. Upon admission, the resident presented with a complex medical history, including lobar pneumonia, acute respiratory failure, hypocalcemia, hypothyroidism, depression, atopic dermatitis, and other chronic conditions. Observations and record reviews revealed the presence of a foam dressing on the resident's right lower leg, a physician's order for wound care, and documentation of multiple skin impairments such as bruising, non-blanchable redness, a small pressure area, discoloration, and a skin tear. Despite these findings, the baseline care plan did not include any focus or interventions for skin integrity. Interviews with facility staff confirmed that the omission was due to the nurse not checking off skin integrity in the comprehensive assessment upon admission. Both the Minimum Data Set Coordinator and the Director of Nursing acknowledged that the baseline care plan should have addressed the resident's skin integrity, given the documented skin issues and physician orders for wound care. The facility's policy requires that a baseline care plan be developed within 48 hours of admission, but this was not followed in this case.