Failure to Implement and Monitor Skin Integrity Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned interventions and timely identify and treat skin impairments for a resident with severe cognitive impairment, cerebral palsy, and a history of pressure ulcers. The resident was dependent on staff for all activities of daily living, including incontinence care, and had orders for regular skin checks and the application of moisture barrier ointment. Despite these orders, documentation and staff interviews revealed that skin assessments were not consistently performed, and the resident's skin condition was not properly monitored or reported. Observations showed that the resident developed extensive skin breakdown, including large reddened areas, open wounds, and bleeding on the lower back, buttocks, and hips. Multiple staff members, including CNAs and LPNs, either did not notice or did not report the worsening skin condition, and some were unsure if the required interventions had been completed. The low air loss mattress, intended to prevent pressure injuries, was found to be malfunctioning with a low pressure warning, but there was no indication of how long it had been inoperable or if it had been reported or addressed in a timely manner. Interviews with staff revealed a lack of communication and documentation regarding the resident's skin condition. CNAs reported seeing redness and applying barrier cream but often did not inform the nurse, assuming the nurse was already aware. Nurses admitted to checking off treatments and skin checks on the Treatment Administration Record without actually assessing the resident's skin, relying on CNAs to report any issues. The facility's policy required reporting of skin breakdown, but this was not consistently followed, resulting in delayed identification and treatment of the resident's skin impairments.