Failure to Identify and Report Abdominal Skin Tear During CNA Skin Check
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with a non‑pressure related skin impairment received appropriate treatment and services in accordance with professional standards of practice. The resident had multiple complex medical conditions, including chronic respiratory failure with hypoxia, tracheostomy with ventilator dependence, hemiplegia, hemiparesis, and vascular dementia, and lacked decision‑making capacity, with her daughter designated as responsible party. On the day of transfer to an acute care hospital, CNA documentation in the electronic medical record indicated that the resident received a complete linen change, face care, peri care, and a shower. During a concurrent interview and record review, the CNA/RNA who assisted with the shower stated that facility process requires CNAs to perform skin checks during incontinent care, bed baths, and showers, and to report abnormal findings to the wound care nurse or charge nurse. The CNA/RNA reported that she performed a skin check during the shower and noted no abnormal findings to report, and that she applied triad barrier cream to the resident’s abdominal folds. However, a photograph taken later that day in a general acute care hospital emergency room showed a skin tear covered with white cream on an abdominal fold, which the CNA/RNA acknowledged would have been an abnormal finding that should have been reported to the wound care nurse and that she had not identified during the shower. Subsequent review with the SNF nurse manager and the wound/ostomy nurse from a second acute care hospital confirmed that the resident arrived at the hospital with a left abdominal fold skin tear. The second hospital’s admission process included a skin assessment and photograph of the left abdominal fold skin tear, and the wound/ostomy nurse identified it as such. The SNF nurse manager, after reviewing the hospital photographs, stated that the photos indicated a left abdominal skin tear and that CNAs are expected to identify and report such abnormalities during routine skin checks. The facility’s CNA job description and the skin care and pressure injury prevention policy both require CNAs to monitor and report noticeable changes in residents’ skin condition and to routinely assess for signs of irritation or breakdown, which did not occur in this instance.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.