Failure to Evaluate and Document Skin Condition in Dependent Resident
Penalty
Summary
The facility failed to evaluate and document a red area on a resident's bottom following her readmission after a hospital stay. Upon admission, the resident was noted to have redness on her sacrum, but there were no documented measurements or identified causes for the redness. Over the next three weeks, weekly skin assessments indicated no new skin issues and described the skin as clear and intact, despite the presence of the red area. Staff interviews confirmed that the redness was not measured or evaluated, and there was no follow-up documentation regarding its progression. The resident involved had significant medical conditions, including respiratory failure, pneumonitis, dysphagia, aphasia, Alzheimer's disease, and diabetes, and was dependent on staff for all activities of daily living. She was always incontinent of urine and feces, increasing her risk for skin breakdown. Observations revealed that the resident continued to have a large, purple/red area with peeling skin on her bottom, and staff confirmed that daily treatments were being performed without proper documentation or evaluation of the wound's status.