Failure to Complete Timely and Appropriate Skin Assessments
Penalty
Summary
The facility failed to ensure appropriate and timely routine skin assessments for two residents with altered skin integrity. For one resident, the medical record showed an admission with multiple complex diagnoses, including diabetes, kidney failure, and schizoaffective disorder. Upon admission, a red area was noted on the right buttock, but the assessment lacked details such as size, etiology, drainage, or surrounding tissue condition. There was no evidence that the physician was notified or that interventions were initiated at the time the skin issue was identified. Although physician orders required a Braden skin assessment on admission and weekly for three weeks, only the initial assessment was completed, and it did not reflect the resident's actual mobility status or the presence of the skin issue. No ongoing skin assessments or documentation of the skin condition's resolution were found during the resident's stay, despite continued use of topical treatments and a care plan indicating actual skin impairment. For the second resident, who had diagnoses including multiple sclerosis, COPD, and chronic kidney disease, the care plan addressed an actual skin impairment of the coccyx but did not address the risk for impaired skin integrity due to mobility and incontinence issues. The resident developed an unstageable pressure injury that was not present on admission. Documentation showed that only two weekly skin assessments were completed over several months, and there were no nursing progress notes related to the new skin issue when it was identified. After a re-entry to the facility, physician orders for Braden skin assessments were not followed, and no such assessments were documented. Interviews with facility staff, including the DON, RN, and LPN Unit Manager, confirmed that weekly skin assessments were required and should be documented in the electronic medical record. Staff interviews also revealed uncertainty about the process for notifying the wound nurse of new skin concerns and inconsistent communication regarding skin integrity issues. Review of facility policy indicated that all residents should have routine skin assessments, with documentation at least weekly, but this was not followed for the residents in question.