F0726

D

Incomplete Weekly Skin Assessment Leads to Missed Stage 2 Pressure Areas

Oklahoma City, Oklahoma Survey Completed on 02-18-2026

Penalty

Fine: $50,116

Summary

The facility failed to ensure accurate completion of a weekly skin assessment for one resident, resulting in missed identification of multiple open areas on the coccyx and buttocks. The resident had diagnoses including an unspecified fracture of the sacrum and abnormalities of gait and mobility, and was cognitively intact with a BIMS score of 15. A physician order dated 01/23/26 required a weekly skin assessment every Thursday on the night shift. On 02/12/26 at 10:40 a.m., the resident was observed during incontinent care with three open areas on the coccyx and buttocks. However, a skin assessment documented later that same day at 10:58 p.m. by the charge nurse indicated there were no open areas and only noted a reddened coccyx.

Subsequent documentation and interviews confirmed the discrepancy. A wound care nurse’s skin assessment on 02/13/26 identified three stage 2 open areas: one on the right buttock measuring 1.5 cm by 1.5 cm, one on the left buttock measuring 1.5 cm by 1.5 cm, and one on the upper buttocks measuring 1 cm by 0.5 cm. The resident had also stated on 02/10/26 that they had a small open area on their bottom. The DON acknowledged that the 02/12/26 weekly skin assessment showed no open areas, and LPN #1 later stated they did not perform a complete head-to-toe skin assessment and, to their knowledge, did not visualize the coccyx and buttocks during the weekly skin assessment, despite facility training that weekly skin assessments must include all areas of the skin.