Failure to Perform Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards of practice by not performing weekly skin assessments as ordered by the physician for one resident. The facility's policy required comprehensive skin checks to be performed at a frequency consistent with physician orders and for findings to be documented immediately. The resident in question had a history of type 2 diabetes mellitus, bilateral osteoarthritis of the knees, and dementia. A physician's order specified weekly skin and nail checks every Tuesday during the day shift. Documentation showed that a skin check was performed on one occasion, noting abdominal fold irritation and redness, but there were no further skin assessments or documentation of skin issues after that date. Subsequently, the resident was transferred to the hospital due to a change in mental status and abnormal vital signs. Hospital records indicated the resident was diagnosed with sepsis and acute renal failure, and further examination revealed swelling and a wound on the right lower extremity, which required surgical intervention. Interviews with facility staff, including the DON and the nurse assigned to the resident on the day of transfer, revealed they were unaware of any skin issues or wounds, and the facility could not provide evidence that weekly skin assessments had been performed as ordered.