Failure to Perform Timely Head-to-Toe Skin Assessment After New Skin Tear
Penalty
Summary
A deficiency occurred when staff failed to perform a head-to-toe skin assessment immediately after discovering a new skin tear on a female resident with Alzheimer's Disease and severe cognitive impairment. The resident was identified as being at risk for impaired skin integrity due to incontinence, friction/shear, and decreased mobility, with care plan interventions requiring weekly and as-needed skin inspections. On the day the skin tear was found, the MDS nurse noted the injury and informed the charge nurse, but neither conducted a full head-to-toe assessment as required by facility policy and professional standards. Documentation shows that a skin assessment was not performed on the day the wound was discovered. Interviews with the wound care nurse, MDS nurse, and charge nurse confirmed that all were aware of the need for a comprehensive skin assessment after a new wound is found, but each believed the responsibility lay with another staff member. The facility's policy required detailed documentation of skin assessments, including wound description and other relevant observations, which was not completed at the time of the incident. The deficiency was identified through observation, record review, and staff interviews, with the resident's skin tear later observed to be nearly healed.