F0686

D

Failure to Perform and Document Ongoing Skin Assessments for At-Risk Resident

Rockford, Illinois Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete thorough initial and ongoing skin assessments for a resident at risk for skin breakdown who had documented redness to the buttocks and peri-area. The resident had multiple diagnoses including diabetes, atherosclerosis of the aorta, asthma, hypothyroidism, GERD, cataracts, dysphagia, lack of coordination, and gait/mobility abnormalities. A facility assessment showed moderate cognitive impairment, dependence on staff for toilet hygiene, substantial to maximal assistance needs for personal hygiene, and supervision for bed mobility. An order dated 12/16/25 directed application of zinc barrier cream to the buttocks twice daily and as needed for incontinence, and a care plan initiated the same day identified impaired skin integrity related to incontinence with erythema, excoriation, and skin breakdown to the peri-area and buttocks.

Despite these identified risks and care needs, the electronic medical record contained no documented nursing skin assessment of the buttocks from 12/16/25 until the resident’s transfer on 1/16/26. A progress note on 12/25/25 stated that zinc barrier cream to the buttocks and perineal area continued and that the area remained stable, but did not include wound classification, size, tissue description, or drainage. A shower sheet dated 1/6/26 documented redness to the buttocks, yet there was still no corresponding nursing skin assessment with detailed wound characteristics. When the resident was sent to the hospital on 1/16/26 for abnormal labs, the emergency department record documented a sacral ulcer.

Staff interviews confirmed the lack of thorough and ongoing skin assessments. A CNA reported the resident had a “real red area” on her buttocks and that barrier cream was applied, and stated CNAs report skin issues to nurses. The RN who sent the resident to the hospital acknowledged she did not inspect the resident’s skin before transfer, had last seen the resident’s bottom 3–4 days earlier, noted redness and irritation, and admitted she did not document skin assessments, only the barrier cream on the treatment record without size or description. The DON confirmed there were no skin/wound assessments since 12/16/25 except for a brief 12/25/25 note and stated she would expect location, appearance, and size to be charted. The wound care nurse described documenting only what she saw visually and monitoring without consistent, detailed assessments, and acknowledged the resident had persistent redness to the peri-area and buttocks and that it was possible the wound opened. The facility’s wound policy required weekly assessment and documentation of any skin impairments by the wound nurse or designee, which was not followed for this resident.