F0684

D

Failure to Identify and Treat Hand Skin Breakdown Related to Overgrown Nails and Contractures

Hickory, North Carolina Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete thorough skin assessments and obtain appropriate treatment orders for a reddened area on a resident’s right palm caused by an overgrown fingernail in the setting of bilateral hand contractures. The resident had diagnoses including COPD, diabetes mellitus, bilateral hand contractures, and dementia, and was severely cognitively impaired, requiring total assistance with all ADLs except eating. Physician orders included a weekly head-to-toe skin assessment on a specific shift and an order for bilateral palm guards with instructions to check skin integrity prior to application. The care plan identified the resident as having an ADL self-care performance deficit and an alteration in musculoskeletal status related to bilateral hand contractures, with interventions that included adaptive equipment, bilateral hand splints, good hygiene, skin monitoring, and notification of the provider for complications.

Despite these orders and care plan interventions, multiple assessments and observations failed to identify and address a reddened area on the resident’s right palm caused by his middle fingernail pressing into his palm. A weekly skin assessment documented that the resident’s fingernails were cleaned and trimmed and that there were no new skin abnormalities, even though later observations showed long fingernails extending approximately 1/4 inch beyond the fingertips and an indentation in the right palm matching the middle fingernail. The reddened area on the palm measured approximately 0.2 cm by 0.2 cm by 0.1 cm and appeared to have been open at one time but was no longer open, remaining red in color. Staff, including the MDS coordinator and nurses, reported that they did not remove the resident’s splints or palm guards during assessments and were not aware of any skin issues on his hands.

Over several days, surveyor observations documented that the resident’s fingernails remained long, that the middle finger continued to press into the palm, and that there was a malodor and moist exudate previously noted in the right hand by staff. The resident himself stated that he wanted his fingernails trimmed because he did not like them long as they dug into the skin of his hand, and he reported that no one had discussed cutting his fingernails with him. Nurse aides and nursing staff acknowledged noticing foul odor and moist exudate in the right hand at times and cleaning and drying the area, but they had not identified or reported the reddened area caused by the fingernail until it was pointed out during observations. The wound nurse was never notified of any skin issue on the resident’s right hand, and unit management and therapy staff were unaware of the reddened area until the time of the surveyor’s observations and interviews, demonstrating that the ordered and care-planned skin monitoring and assessment processes were not effectively carried out for this resident.

Facility leadership, including the DON and Administrator, stated that nurses should have been checking the resident’s hands and palms daily and during weekly skin assessments, removing palm guards to thoroughly observe the skin, and recognizing and reporting new skin issues for treatment and further evaluation. However, the documented assessments and staff interviews show that these actions did not occur, resulting in the reddened area on the resident’s right palm from his middle fingernail pressing into his skin going unrecognized and untreated over time.