Failure to Document and Follow Up on Skin Assessments
Penalty
Summary
The facility failed to document follow-up skin assessments for a resident with known skin concerns, including a stasis ulcer, skin tear, and bruising. The resident, who had a history of left femur fracture, Alzheimer's Disease, and peripheral vascular disease, was identified as being at risk for pressure ulcers. Upon admission, the resident had a stasis ulcer on the right ankle, a surgical incision to the left thigh, and a skin tear on the left elbow, but the initial skin observation tool did not include wound measurements. Subsequent skin and wound evaluations recorded limited measurements and lacked details such as drainage, odor, and wound appearance. There was also a gap in documentation of skin assessments for the right ankle ulcer between early and late May, and new skin concerns such as bruises and a skin tear were not fully documented or measured. Staff interviews revealed inconsistent practices regarding skin assessments and documentation. The DON acknowledged that weekly skin assessments were not consistently completed or documented in the electronic health record (EHR), and that incident reports were not always filled out when new skin concerns were identified. Nursing staff described procedures for reporting and assessing skin issues, but there were discrepancies in how and where assessments were documented. One LPN reported being unable to document or photograph bruises due to technical issues, and another staff member indicated that nothing in the EHR flagged the need for attention to the resident's skin concerns. Observations confirmed the presence of unreported or undocumented bruises and wounds on the resident, including a large dark purple bruise on the forearm and scabs on the arm. The resident expressed discomfort during care and indicated that certain areas were painful. The facility's policy required the use of a communication form and thorough assessment for any change in condition, including new skin issues, but these protocols were not consistently followed, resulting in incomplete documentation and follow-up of the resident's skin concerns.