Failure to Complete Weekly Wound Assessments and Ensure Proper Skin Interventions
Penalty
Summary
The facility failed to ensure that weekly comprehensive wound assessments were completed, appropriate skin interventions were in place, and wounds were accurately classified for two residents reviewed for wounds. For one resident with multiple complex diagnoses, including chronic kidney disease, malnutrition, and dependence on dialysis, the initial assessment upon admission identified excoriation and Moisture Associated Skin Damage (MASD) to several areas. Although the care plan included weekly head-to-toe skin assessments and specific interventions, there was no documented weekly comprehensive assessment of the MASD until nearly a month after admission. Interviews with the wound nurse and DON confirmed that weekly assessments should have been performed and documented. Another resident with a history of end-stage renal disease, severe malnutrition, bilateral lower limb amputation, and other comorbidities was admitted with a stage III pressure injury and later developed an unstageable pressure ulcer to the left below-knee amputation site. The care plan required weekly skin assessments, offloading, and use of pressure-relieving devices. However, observations revealed the resident's wound was not offloaded, and the air mattress was set incorrectly for the resident's weight, providing no effective offloading. Documentation inconsistencies were also identified, with the DON confirming that an LPN had been documenting wounds incorrectly or not at all, and the wound was later reclassified as vascular in origin by a wound nurse practitioner. Review of facility policy indicated that residents with wounds or at risk for skin compromise should receive ongoing monitoring, evaluation, and appropriate documentation of skin impairments until resolved. The deficiencies were identified through observation, record review, and staff interviews, and were cited under a complaint investigation and as a recite to the annual survey.