F0684

D

Failure to Measure and Document New Skin Tear per Wound Care Policy

N Hollywood, California Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s skin condition was assessed and documented according to professional standards of practice and facility policy, resulting in an incomplete medical record. The resident was admitted with diagnoses including multiple right rib fractures, diabetes mellitus, and essential hypertension, and had documented cognitive impairment and lack of decision-making capacity. A skin assessment dated 2/5/2026 showed the resident had a right outer forearm skin tear and a left cheek abrasion following an altercation in which another resident entered the room, the resident raised a walker in defense, lost balance, and hit the wall. An SBAR communication form documented the incident and the resulting right forearm skin tear and left cheek abrasion.

During interview, the Treatment Nurse stated he performed the skin check on 2/5/2026, noted the right forearm skin tear and left cheek abrasion with minimal bleeding, but did not measure the skin tear and acknowledged he does not measure skin issues all the time, despite stating that measurements should be done with any new skin changes to track improvement. The DON confirmed the Treatment Nurse should have measured the skin tear and that, without measurements, the facility would not know if the skin tear was getting better or worse or if treatment was effective, and that the medical record was incomplete and facility policy was not followed. Review of the facility’s Wound Care policy required that all assessment data, including wound size, be recorded, and the Investigating Resident Injuries policy required objective, sufficiently detailed descriptions, including dimensions of injuries, which were not documented in this case.