Failure to Consistently Assess and Document Non-Pressure Skin Conditions
Penalty
Summary
The facility failed to assess, monitor, and document non-pressure skin conditions in accordance with its policy and the resident’s care plan for one resident with cellulitis and a skin tear. The facility’s wound policy required weekly monitoring and documentation in the electronic medical record for wounds such as diabetic ulcers, significant skin tears, and other skin conditions, including size, color, odor, healing progression, notifications, and other pertinent information. On admission, the Skin Grid form documented cellulitis on both of the resident’s lower legs, wrapping around the calf and measuring 1.5 feet long, but no subsequent Skin Grid forms were found in the record for ongoing cellulitis monitoring. The resident’s care plan documented cellulitis on both lower legs and directed weekly and as-needed assessment, including measurements and evaluation of the wound perimeter, wound bed, and healing progress, and was later updated to include a left lower calf skin tear with instructions for nursing to monitor and document location, size, and treatment. The Total Body form dated 12/16/2025 showed a 3 cm round open skin tear on the resident’s left lower leg, but there was no further documentation of additional assessments of this skin tear and no additional Total Body forms in the record. The admission assessment documented diagnoses including cellulitis and diabetes, and that the resident was able to make needs known. A nurse progress note dated 01/02/2026 described a wound on the left lower leg as red, without odor or drainage, painful, with scaly surrounding skin, but did not specify whether this referred to the cellulitis or the skin tear, despite both being located on the left lower leg. Interviews with the RCM, an LPN, and the DNS confirmed that facility practice and expectations were for weekly Total Body forms and Skin Grids, with assessment, measurement, and evaluation of non-pressure skin issues, including cellulitis, but the resident’s record lacked consistent weekly documentation and clear identification of the wounds being assessed.
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