Failure to Complete Thorough Head-to-Toe Skin Assessment
Penalty
Summary
A facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, an elderly male with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and skin cancer, was at risk for pressure ulcers and had documented interventions requiring regular skin assessments, particularly due to his incontinence and decreased mobility. The care plan and physician orders required weekly head-to-toe skin assessments, with special attention to skin condition and signs of breakdown. On several occasions, staff documented that head-to-toe skin assessments were completed, but interviews and record reviews revealed that these assessments were not thorough. Specifically, on the day before the resident was sent to the hospital, the nurse responsible for the assessment admitted she did not examine the resident's groin area, stating she did not suspect any issues and the resident did not complain of discomfort. Other staff also reported difficulty in providing care due to the resident's dementia and reluctance to allow assistance, but there was no documentation or evidence that a complete skin assessment, including all skin folds and creases, was performed as required by facility policy. The deficiency became evident when the resident was found to have a draining, foul-smelling abscess in the left groin area, which was only discovered after a family member insisted on a more thorough examination. The abscess required surgical intervention after the resident was transferred to an acute care hospital. Interviews with staff confirmed that the required comprehensive skin assessments were not fully completed, particularly in the groin area, despite policy and care plan directives to examine all areas of the body, including moist areas and skin folds.