Failure to Document Nursing Assessment After Skin Issue Identified
Penalty
Summary
A deficiency occurred when the facility failed to document a nursing assessment after a bath aide identified an open, red, and bleeding scrotum on a resident. The resident, who had diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease, was dependent on staff for toileting hygiene and required substantial assistance with transfers. The resident was also at risk for pressure ulcers. The Certified Nursing Assistant (CNA) documented the skin issue on a shower review form, but there was no evidence in the progress notes from the date of discovery through several days later that a nurse assessed the area or that a physician was notified. Interviews revealed that the CNA reported new skin issues using a designated form, which was then placed in the MDS Coordinator's mailbox. The MDS Coordinator charted a note several days after the initial finding but did not verify that the area was tracked or monitored. The Director of Nursing (DON) was not made aware of the issue at the time and did not assess the area until days later, by which time only chronic redness was observed. Facility policy required notification of the DON and wound nurse for new skin alterations, completion of incident reports, and physician notification if deterioration or infection was observed, but these steps were not documented as completed in this case.