Failure to Identify and Treat Resident Skin Tears
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to assess, document, and treat two skin tears on a resident with multiple risk factors for skin breakdown. During observation, the resident was seen in a wheelchair with a quarter-sized open area on the left shin and the right leg wrapped in a dressing showing two golf ball-sized areas of dried serosanguinous fluid on the calf. The resident stated that his legs “always be like that” and that he sometimes hits his legs on the wheelchair. The resident’s diagnoses included chronic venous hypertension with ulcer of the left lower extremity, left lower leg venous ulcer, peripheral vascular disease, cellulitis of the right lower limb, and type 2 diabetes mellitus with unspecified complications. His BIMS score indicated moderately impaired cognition, and his Braden Scale score of 16 indicated mild risk for pressure ulcer development, which under facility policy required weekly skin assessments. When the wound care nurse was interviewed shortly after the observation, she reported that as of several days earlier there were no open areas on the resident’s legs, that there were no current treatments because everything was crusted over, and that the right leg was wrapped per the resident’s preference. At that time, the facility had no documented treatment orders or wound assessments for the observed open areas. Later that morning, the physician assessed the resident and identified a left shin skin tear measuring approximately 4 cm by 1 cm and a right calf skin tear measuring approximately 4 cm by 6.2 cm, stating the resident might have hit his legs on something. The medical record, including the most recent MDS, did not reflect any unhealed pressure ulcers or skin tears, and the wounds were not documented as present on admission. The facility’s own policy required that residents at mild and moderate risk receive weekly skin assessments, and that skin be inspected during routine care with attention to lower extremities, but evidence in the record and staff statements showed the facility was unaware of the resident’s skin tears until after the surveyor’s observation and physician assessment.
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