Failure to Complete Timely and Accurate Skin Assessment on Admission
Penalty
Summary
The facility failed to perform an initial full body skin assessment and implement timely interventions for a resident upon admission, as required by its Skin Assessment Policy. Upon review, the admission screening indicated the resident's skin was intact, but a subsequent body check performed within 24 hours identified edema in both lower extremities and excoriation to both buttocks. The initial assessment did not document these findings, and the discrepancy was acknowledged by the Director of Nursing, who stated that the excoriation may have been missed during the first assessment. The resident in question had significant medical conditions, including aphasia, hemiplegia, hemiparesis following a stroke, diabetes, and major depressive disorder. The resident required one-person assistance for transfers and was incontinent of urine and frequently incontinent of bowel. Despite these risk factors, the initial skin assessment failed to identify the presence of skin impairment, and the need for wound care with Zinc Oxide was not recognized until the second assessment was completed by another nurse. Interviews with facility staff revealed that if skin issues were identified, an incident report should have been initiated and documented in the electronic medical record, but this was not done. The Treatment Administration Record indicated that a previous skin impairment was present, but there was no corresponding documentation in the progress notes or incident reporting. The delay in identifying and treating the skin impairment resulted in a delay in the administration of prescribed wound care.