F0684

D

Failure to Measure and Document Skin Redness per Wound Monitoring Policy

Chatsworth, California Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Skin and Wound Monitoring and Management policy by not measuring a documented skin change for a resident. The resident was readmitted with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, right eye blindness, history of TIA, and cerebral infarction without residual deficits, and had an MDS indicating severely impaired cognition and dependence on staff for oral, toileting, personal hygiene, and movement. On the morning of 2/5/2026, a CNA reported redness on the resident’s right lateral abdomen to the treatment nurse, and a Change in Condition (COC) form was completed documenting this skin issue. Later that same day, a physician’s order was obtained to apply triple antibiotic ointment daily to the right lateral abdomen for irritation/scratch.

During interview and record review, the treatment nurse acknowledged being notified of the skin-related COC on 2/5/2026 and stated that treatment nurses are responsible for assessing the area, measuring it, notifying the physician, and informing the resident or responsible party. However, the treatment nurse admitted not measuring the redness at that time, explaining they did not think it was necessary and did not believe the condition was serious. A subsequent COC dated 2/8/2026 documented that the irritation had increased in size, but the treatment nurse could not explain how this was determined without measurements. The Assistant DON confirmed there were no measurements documented for the 2/5/2026 skin COC and stated the treatment nurse should have measured the affected area, noting that the facility’s policy requires licensed nurses to assess and evaluate each pressure and non-pressure injury, including measuring the skin injury and describing its nature, location, and characteristics.