Failure to Timely Assess and Treat Non-Pressure Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to timely assess and implement treatment for a non-pressure skin condition in one resident. The resident was admitted with multiple serious diagnoses, including respiratory failure with hypoxia, cerebral edema, protein-calorie malnutrition, cerebral infarction, metabolic encephalopathy, hypokalemia, convulsions, paroxysmal atrial fibrillation, peripheral vascular disease, and pneumonia. An MDS assessment documented that the resident had severe cognitive impairment and was fully dependent on staff for all ADLs. The resident’s care plan, last revised on 11/19/25, identified risk for skin alteration related to generalized weakness, decreased strength and endurance, decreased activity tolerance, impaired mobility, impaired cognition, and incontinence, with interventions to administer treatments as ordered, monitor effectiveness, and assess and record wound healing, including measurements of length, width, and depth, following facility protocol. Despite these identified risks and care plan interventions, the admission assessment documented that the resident was admitted with moisture-associated dermatitis to the coccyx, and the facility did not perform any skin assessments from 09/02/25 through 09/29/25. Additionally, there were no treatment orders in place for the coccyx moisture-associated dermatitis until 09/25/25. Wound Nurse #586 confirmed the absence of documented skin assessments during this period and the lack of treatment orders for the dermatitis until that later date. The DON confirmed the expectation that staff should chart and treat skin issues until they are resolved. Facility policy on wound care, last revised 8/25, required staff to measure wounds, including length, width, and depth, and apply treatments as indicated. This non-compliance was investigated under multiple complaint numbers as cited in the report.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.