Failure to Complete and Document Required Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of quality by not completing and documenting required skin assessments for a resident who developed a lump on the forehead and was later discharged. The resident, admitted from home for a planned five-day stay with hospice services, had diagnoses including Parkinsonism unspecified, essential tremors, and atrial fibrillation. An incident report documented by an LPN noted a lump on the resident’s left forehead with no discoloration, no pain, and no identified injuries. However, the electronic medical record from the date of the incident through discharge contained no documentation that a skin assessment was completed following the identification of the lump. Additionally, there was no documented skin assessment prior to the resident’s planned discharge, despite interviews indicating that it was standard protocol and expectation for nurses to complete a head-to-toe and skin assessment on admission, with any identified skin changes, and prior to discharge. The DON, an LPN responsible for the discharge assessment, the administrator, and the LPN who identified the lump each acknowledged in interviews that a skin assessment should have been completed and documented in these circumstances. After discharge, the resident’s representative reported multiple skin issues, including a lump on the forehead, a laceration above the left ear, bruising to the left side/underarm, and genital excoriation, which were not documented in the facility’s records.
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