Failure to Assess and Monitor Non-Pressure Skin Lesions
Penalty
Summary
The facility failed to adequately assess and monitor non-pressure related skin abrasions for a resident with a history of Type 2 diabetes mellitus, dermatitis, prurigo, bipolar disorder, and previous MRSA skin infection. Despite the resident's care plan instructing staff to monitor skin integrity and report concerns, documentation and observation revealed that open and scabbed lesions on the resident's right lower extremity (knee to thigh) were not identified, assessed, or documented in a timely manner. Weekly skin inspection records and nursing progress notes did not reflect the presence of these lesions, and staff interviews confirmed that the lesions had been present for several days without being reported to the provider or nurse manager. Nursing assistants and registered nurses were unaware of the new and existing lesions until prompted by surveyor observation and interviews. The nurse manager confirmed that there was no documentation or provider notification regarding the new and scabbed lesions, despite the resident's history of skin infections. The facility's process for monitoring and reporting non-pressure related skin concerns was not followed, as evidenced by the lack of timely assessment, documentation, and communication among staff regarding the resident's skin condition.