F0600

G

Failure to Assess, Monitor, and Accurately Report Resident Skin Condition Resulting in Hospitalization for Cellulitis

Montrose, Michigan Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent neglect of a resident by not adequately assessing, monitoring, and documenting a known skin condition, and by inaccurately reporting the resident’s skin status at discharge. The resident had multiple significant diagnoses, including vascular dementia, hemiplegia, and a prior history of a coccygeal pressure ulcer that had reportedly healed months earlier. A quarterly assessment showed a BIMS score of 2/15, indicating severe cognitive impairment. Despite this, the resident’s care plan identified risks related to incontinence and impaired skin integrity, with interventions directing staff to observe for redness or breakdown, provide peri-care after incontinence episodes, apply barrier cream, and notify nursing and the physician of new skin issues.

A CNA documented a new red skin area on the resident on 01/01/2026, triggering an alert note on 01/02/2026. The wound care nurse documented only that there were “no areas of concern noted at this time,” without describing the location, appearance, or size of the new skin problem, and without a detailed skin assessment note. On 01/04/2026, a nurse entered an order for zinc oxide ointment to be applied to the coccyx twice daily and as needed for a red area, and the MAR shows this treatment was documented as given 63 times from early January through the resident’s discharge on 02/05/2026. However, there were no supplemental progress notes or skin assessments describing the coccygeal area’s condition, progression, or resolution, and weekly skin assessments repeatedly documented “no new” and “no existing” abnormal skin areas, despite the ongoing treatment order for a red coccyx. CNA point-of-care charting in February continued to note red and discolored skin areas, marked as not new, but these findings were not reflected in nursing skin assessments.

Interviews with staff and others further demonstrated inconsistent recognition and follow-through on the resident’s skin condition. The resident’s former roommate reported that at night CNAs would sometimes only ask if the resident was wet and, if he said no, would not check or change him, resulting in the resident “sitting in piss.” CNAs who provided care stated that the resident’s bottom was very red, with dead skin and leaking fluid, and that nurses were aware and applying treatment creams, but they could not specify what was reported or when. Nurses recalled the resident having eczema and dry skin, and one nurse acknowledged the coccyx was red but not open, yet no detailed assessments were documented. The wound care nurse stated that she did not follow blanchable redness and did not document an assessment beyond the alert note. On the day of discharge, the discharge was described as rushed, no body skin assessment was performed, and the nurse completing the discharge summary documented “no skin issues noted” in the nursing skin/wound section. The receiving facility and family, upon assisting the resident to the restroom shortly after arrival, observed extensive redness from the lower back to the legs, open and weeping areas on the buttocks, and bloody fluid on the brief, leading to hospital transfer where the resident was diagnosed with a large area of cellulitis on the lower back and suspicion of elderly neglect.

The hospital records documented redness along the sacral region extending to the back, excoriation throughout the coccygeal region, hyperemia, satellite lesions compatible with possible fungal infection, and evidence of secondary infection. Laboratory results showed an elevated white blood cell count, and the resident reported pain at 10 out of 10. The resident required IV antibiotics, antifungal cream, and narcotic pain medication during a five-day hospitalization and was discharged with continued oral antibiotics. The facility’s own abuse, neglect, and exploitation policy defined neglect as failure to provide necessary goods and services to avoid physical harm and pain, and job descriptions for RNs and LPNs required assessment, documentation of resident condition and nursing needs, and documentation of treatments and pertinent observations. Despite these requirements, the facility did not complete or document adequate skin assessments after a new skin concern was identified, did not ensure appropriate treatment follow-up and monitoring, and inaccurately documented that there were no skin issues at discharge, while the resident’s skin condition had progressed to cellulitis requiring hospitalization.

Family members and the evaluating agency reported that they had not been informed of any ongoing skin issues prior to discharge and that the discharge paperwork and verbal report from the facility indicated no skin problems other than use of barrier cream. The family and receiving facility staff were shocked by the condition of the resident’s skin upon arrival, and the hospital documented a high suspicion for elderly neglect. The DON, upon review of the records, acknowledged that the wound care alert note lacked essential information, that the coccyx area being treated was not documented in skin assessments, and that there was no documentation to show whether the skin condition improved, worsened, or resolved from the time it was first identified until discharge. This sequence of incomplete assessment, lack of monitoring and documentation, and inaccurate discharge information constituted the neglect that led to the resident’s hospitalization for cellulitis and treatment with IV antibiotics.

The facility’s own policies and staff job descriptions required prevention of neglect, ongoing oversight, and documentation of resident conditions and treatments. However, the record shows that after the CNA’s initial identification of a new red area, the wound care nurse did not document a detailed assessment, nurses did not create progress notes describing the coccygeal skin condition despite repeatedly applying treatment, and weekly skin assessments failed to acknowledge any abnormal skin areas. On the day of discharge, no skin assessment was performed, yet the discharge summary stated there were no skin issues. These actions and omissions, combined with reports of inconsistent incontinence care and the subsequent findings at the receiving facility and hospital, demonstrate that the resident was not protected from neglect related to skin care and monitoring.