F0684

D

Failure to Complete Timely Post-Readmission Skin Assessment

Pleasant Hill, Iowa Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to perform timely and complete skin assessments following a resident’s readmission from the hospital, despite existing policies and care plan directives. The resident had diagnoses including sepsis, weakness, and a need for assistance with personal care, and was cognitively intact with a BIMS score of 15/15. The facility’s pressure ulcer/skin breakdown policy required nursing staff to examine the skin of newly admitted residents for evidence of pressure ulcers or other skin conditions, and the resident’s care plan directed staff to monitor and document the location, size, and treatment of skin injuries and to report abnormalities. Prior to hospitalization, the care plan documented moisture-associated skin damage to the buttocks.

Nurses’ notes showed the resident was sent to the hospital for sepsis and later readmitted. On the day of readmission, the resident refused a full skin check because he wanted to remain in his chair for dinner. The record lacked documentation that staff reapproached the resident for a skin check, including assessment of the buttocks, between the date of readmission and several days later. A subsequent skin issues note documented a new buttocks wound with specific measurements and a pink/red wound bed. The Wound Nurse stated that the nurse completing admissions was responsible for head-to-toe skin assessments and acknowledged there was likely an assumption that the admitting nurse had completed the assessment, which contributed to the lack of follow-up. The DON stated that staff should perform skin assessments on the day of admission and, if not done, this should be communicated to subsequent shifts and reattempted if initially refused, which did not occur in this case.