Failure to Accurately Communicate Resident Skin Condition During Transfer
Penalty
Summary
The facility failed to provide accurate and complete information regarding a resident's skin condition during a transfer to another nursing home. Documentation at the time of discharge indicated that a skin check was completed and no new issues were identified, and the discharge paperwork reviewed with the MPOA and receiving nurse did not mention any significant wounds. However, a skin and wound assessment from the same period documented deep tissue injuries to both heels and a surgical wound to the abdomen. Additionally, the pre-admission screening and MDS assessments did not indicate the presence of pressure ulcers. Interviews with staff at the receiving facility revealed that the resident arrived with a dressing on the coccyx, which appeared to cover a severe wound described as deep, malodorous, and possibly to the bone. The body audit conducted at admission to the receiving facility also noted a wound on the coccyx covered with a dressing and redness on both heels. When confronted with this information, the facility's administrator, wound nurse, and DON acknowledged the presence of the dressing but could not explain its origin and denied knowledge of a Stage III pressure ulcer on the coccyx.