Failure to Assess, Document, and Communicate Skin Impairments
Penalty
Summary
The facility failed to adequately assess, document, and communicate changes in a resident's skin condition, specifically regarding buttock redness and subsequent open areas, upon admission and during the resident's stay. Upon admission, the resident, who had a history of vulvar cancer, recent chemotherapy, radiation therapy, and a left humerus fracture, was noted to have buttock redness during the initial skin assessment. However, the assessment lacked detailed documentation regarding the extent, size, and characteristics of the redness, and there was no evidence of follow-up actions or provider notification. The baseline care plan referenced perineal and buttock wounds, but the admission assessment only mentioned buttock redness, and no comprehensive wound assessment or monitoring was initiated for the buttock area. Throughout the resident's stay, there were multiple missed opportunities for timely and thorough skin assessments, documentation, and communication among staff and with providers. Nursing staff did not consistently document the status of the buttock redness or any progression to open areas, and there was no evidence that the provider or wound care team was notified when the skin impairment failed to resolve or worsened. Progress notes and treatment records lacked specific information about the wounds, and the required weekly skin assessment was not completed or documented. Staff interviews revealed a lack of clarity and follow-through regarding protocols for skin impairment assessment, documentation, and escalation, with several staff members unable to recall the resident or the care provided. The resident later reported increased pain and was found by a nurse practitioner to have a stage 2 pressure ulcer with sloughing on the buttocks, which was subsequently confirmed and further described during a hospital admission. The facility's own post-discharge skin evaluation form was incomplete, lacking measurements and detailed descriptions. Interviews with facility leadership and staff confirmed that expected protocols for assessment, documentation, provider notification, and intervention were not followed, and the medical record did not reflect appropriate monitoring or care management for the identified skin impairments.