Failure to Perform Timely Skin Assessment and Pressure Injury Reassessment
Penalty
Summary
A resident with a history of pressure-induced deep tissue damage, mild protein-calorie malnutrition, and adult failure to thrive was readmitted to the facility with an unhealed stage 4 pressure injury on the sacrum. Upon readmission, the resident was dependent on staff for mobility and activities of daily living, was incontinent of urine and stool, and was identified as high risk for pressure injury. The care plan included skin and ulcer treatment, use of a pressure-reducing device, turning and repositioning, and nutrition and hydration interventions. Despite these risk factors and care needs, a thorough skin check was not performed upon the resident's readmission. The admitting RN did not complete a comprehensive skin assessment, citing the resident's refusal to turn, and failed to document the refusal or communicate the need for follow-up to the next shift. Additionally, the treatment nurse did not perform a pressure injury reassessment within 24 hours of readmission, as required by facility policy. The initial wound evaluation after readmission incorrectly documented the pressure injury as stage 3 instead of stage 4, which was only corrected several days later by another nurse. These lapses in assessment and documentation resulted in a delay in identifying and appropriately classifying the resident's pressure injury. The facility's own policies required comprehensive skin assessments upon admission and a reassessment by a treatment nurse within 24 hours, but these were not followed. Interviews with nursing staff and the DON confirmed that the required assessments were not completed in a timely manner, and that the failure to assess and document the resident's skin condition led to a delay in necessary care and treatment.