Failure to Assess and Monitor Skin Integrity in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor the skin condition of a resident who was at high risk for pressure injuries. The resident had multiple diagnoses, including End Stage Renal Disease requiring dialysis, Diabetes Mellitus, and severe calorie malnutrition, all of which increased their risk for pressure injuries. Despite these risk factors and a documented decline in the resident's health status, the facility did not update the plan of care or conduct additional skin assessments when the resident began refusing dialysis, medications, and meals. The last documented licensed nurse skin assessment was completed several weeks prior to the resident's significant health decline. The facility's policy required regular skin assessments and updates to the care plan when a resident's condition changed, but these were not performed. Staff interviews revealed that the wound care nurse only assessed a toe abrasion and did not examine other areas of the resident's body, including the heels or hips. Other staff members, including the nurse manager and nurse practitioner, acknowledged that no comprehensive skin assessment was conducted during the period of the resident's decline, despite increased refusals of care and a need for greater assistance with activities of daily living. When the resident was eventually transferred to the hospital, emergency department documentation and photographs identified four pressure injuries, including unstageable injuries to the hip and back, a stage 1 injury to the ischium, and a deep tissue injury to the heel. Facility records lacked documentation of weekly skin assessments or any revisions to the plan of care in response to the resident's deteriorating condition and increased risk factors. Interviews with facility staff confirmed that no additional skin assessments were performed during this critical period.