Failure to Complete Initial Skin Assessment on Admission
Penalty
Summary
The facility failed to complete an initial skin assessment for one of three residents reviewed for skin assessments during the admission process. Record review showed that the resident was admitted following a recent procedure to implant a defibrillator and was later discharged against medical advice due to concerns of physical abuse, presenting with bruising, swollen genitals, penile bleeding, and various other bruises. Upon review of the resident's medical chart, no initial skin assessment was found, and the Director of Nursing confirmed that the assessment should have been completed by the admitting nurse but was not present in the records. During interviews, the LPN responsible for the admission stated that he did not perform the skin assessment because the resident was fatigued, the unit was busy, and he was occupied with paperwork and the family. The LPN admitted to not removing the resident's clothing to check for bruising or surgical sites and only noted excoriation at the tip of the penis after the resident tugged on his Foley catheter. The LPN did not document any initial assessments, nor did he inform anyone that the skin check was not completed, resulting in the lack of a trigger for follow-up by other staff.