Failure to Complete Admission Skin Assessment for Resident With Existing Wound
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a newly admitted resident received a complete admission skin assessment as required by facility policy. The resident was admitted with multiple diagnoses, including urinary tract infection, spina bifida, asthma, dysphagia, and dependence on a wheelchair for mobility. Physician orders at admission included instructions to encourage and assist with turning and repositioning every shift, to apply Mupirocin 2% ointment to chronic wounds every shift, and later to evaluate and assess a pressure area with a dressing at the coccyx every shift. Despite these orders and the resident’s conditions, the only documentation on the admission date regarding skin was a general notation that the skin was warm and dry, with no further detailed skin assessment completed at that time. A subsequent skin assessment performed several days later by the wound nurse (an LPN) documented a pressure area on the coccyx measuring 1.5 cm by 1.0 cm by 0.2 cm, with a small amount of serosanguineous drainage, a red wound bed, and maceration of the wound edges. The resident’s MDS indicated intact cognition with a BIMS score of 15, bilateral extremity impairment, and an unhealed pressure area to the coccyx. In interview, the wound nurse confirmed that an admission skin assessment had not been completed on the admission date and stated that the admitting nurse is responsible for the initial admission skin assessment, with the wound nurse to complete a second assessment and review admission treatment orders. This lack of an initial admission skin assessment constituted the cited noncompliance.
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