Failure to Perform Timely Skin Assessment on Readmission
Penalty
Summary
The facility failed to perform a skin assessment for a resident upon readmission, as required by facility policy. The resident, who had diagnoses including urinary tract infection and muscle weakness, was dependent on staff for all activities of daily living and was always incontinent of bowel. Upon review of the clinical record, there was no documentation of a skin assessment being conducted at the time of readmission. Orders for wound care were initiated after wounds were identified days later, including deep tissue injuries to both feet, abrasions on the left medial ankle and right hip, and a stage 2 pressure injury on the left hip. A licensed vocational nurse confirmed that no wound or skin assessment was performed at the time of readmission, and that the physician did not assess the resident until six days later. The facility's policy required a comprehensive skin assessment within eight hours of admission or readmission, but this was not completed. As a result, there was a delay in identifying wounds and initiating appropriate wound care for the resident.