Failure to Prevent and Assess Moisture-Associated Skin Damage
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate skin care and prevent moisture associated skin damage (MASD) in accordance with physician orders and care plan interventions for two residents. One resident was admitted with morbid obesity, unsteadiness, heart disease, and osteoarthritis, and was documented as cognitively intact and occasionally incontinent of bowel and bladder. The resident’s care plan required barrier cream application after each incontinent episode and routine checks and changes every 2–3 hours and as needed. Despite a standing order for Calmoseptine ointment to be applied to the buttocks every day and night shift for excoriation, and a weekly skin assessment order, the resident was later observed with red, irritated buttocks, scrotum, and upper thighs, with open bleeding spots, and the resident was unsure how often cream was applied. During an observed peri-care episode, the CNA supervisor and CNA exposed the resident’s buttocks and genital area, revealing significant MASD that had not been reported to or recognized by the wound nurse/ADON until that time. The wound nurse documented MASD to bilateral buttocks, upper thighs, and scrotum in a progress note after being called to assess the resident. A prior skin observation tool entry indicated that one or more wounds or injuries were present, but it did not identify the wound type, location, or include an assessment. The treatment administration record showed that Calmoseptine was signed out as administered every day and night shift in the prior month and in the current month except for one missed administration, and weekly skin assessments were signed as completed with no corresponding progress note documenting skin breakdown on the date a “yes” was recorded. The wound nurse later stated that the last time she assessed the resident’s buttocks was several days earlier and that weekly skin assessment orders were not carried over when the facility switched systems, and there were no new skin assessments documenting the MASD. A second resident, with diagnoses including diabetes, malignant neoplasm of the left breast, osteoarthritis, hypertension, and stress incontinence, had a moderate cognitive deficit and was always incontinent of bowel and bladder and dependent on staff for toileting. The resident’s care plan identified a potential for impaired skin integrity related to aging and disease processes, including redness/gaulding to the buttocks, with an intervention to assess and record changes in skin status. During observed incontinence care, the resident reported soreness in the peri area and asked if it was red; the CNA supervisor confirmed it was a little red and stated she would get cream, and the surveyor observed the peri area to be red and irritated. The wound nurse/ADON later stated that this redness, irritation, and soreness had not been reported to her, although she would have expected such a report. There was no documentation in the resident’s progress notes regarding the peri area being red and sore at the time of the observation, despite a prior facility-wide skin sweep note indicating no new skin issues. The facility’s own pressure/skin breakdown clinical protocol required full assessment and documentation of skin condition, including location and characteristics, which was not reflected in the records for these residents.
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