Missed Weekly Skin Assessment for At-Risk Resident
Penalty
Summary
The facility failed to ensure that weekly skin assessments were conducted as scheduled for a resident identified as being at risk for skin breakdown. The resident had multiple diagnoses, including morbid obesity, lymphedema, chronic embolism and thrombosis, and a hereditary deficiency of clotting factor. The care plan for this resident included interventions such as completing the Braden scale, conducting weekly skin inspections, providing pressure-reducing devices, and performing incontinent care with barrier cream. Despite these interventions being outlined, a scheduled weekly skin assessment was not completed as documented in the electronic health record. Medical record review showed that the resident required significant assistance with activities of daily living and was at risk for pressure ulcers, although none were present at the time. The resident experienced worsening lower extremity edema and redness, prompting physician notification and new orders for care. The Director of Nursing confirmed that the scheduled skin assessment was missed. Additionally, the facility's policy on pressure injury prevention did not specify procedures for weekly skin assessments, only stating that risk evaluations should be repeated per facility schedule and resident risk factors.