The resident, who suffered a cerebral infarction and has moderately impaired cognition, was identified in care plans as vulnerable to skin breakdown due to thin, fragile skin, incontinence and walking problems. Facility policy requires weekly skin assessments for all residents, but nursing staff failed to examine the patient during the weeks of October 6, 13, 20, and 27.
The missed assessments occurred despite the resident's documented risk factors and a care plan revised in August specifically noting the danger of skin breakdown. The patient also has atrial fibrillation, COPD, and high blood pressure.
"The importance of weekly skin assessments was to assess the skin for an issue," the facility's treatment nurse told inspectors on November 12. She confirmed that skin assessments should be performed weekly and that all skin problems should be documented on the weekly assessments.
When questioned about the missing assessments, the Director of Nursing initially said he would check his files for documentation from the missing October dates. He later returned with shower sheets that certified nursing assistants had filled out during the patient's baths.
The shower sheets contained body diagrams where CNAs could mark any skin problems they observed. A nurse had signed off on each sheet. But the Director of Nursing acknowledged a critical gap in this system.
"The nurses were not usually there when a shower was given to assess the skin themselves," he told inspectors. He admitted that expecting CNAs to perform skin assessments was "out of the CNAs' scope of practice" and confirmed that "the weekly skin assessment should be performed by a nurse."
The facility's own skin management policy, last revised in October 2022, states that skin assessments must be documented "at a minimum of every 7 days on a Weekly Skin Assessment." The policy aims to prevent and treat "skin breakdown such as pressure injuries, diabetic ulcers, arterial ulcers, and skin wounds."
Record review showed the resident had a proper skin assessment on October 1, which found no skin issues. The next documented assessment wasn't until November, also showing no problems. But the four-week gap in October violated both facility policy and professional standards for monitoring high-risk patients.
The resident's medical record indicates they usually understand others and are usually understood, despite the cognitive impairment from their stroke. Their BIMS score of 10 places them in the moderately cognitively impaired category, potentially making it difficult for them to report skin problems independently.
Federal regulations require nursing homes to provide treatment and care according to professional standards and comprehensive care plans. The missed assessments represent a failure to follow the facility's own protocols designed to catch skin problems before they become serious.
Inspectors classified the violation as causing minimal harm or potential for actual harm. However, they noted that the failures "could result in skin issues on residents being missed, skin issues deteriorating without being monitored, and decreased quality of life."
The case highlights a common problem in nursing home care, where policies exist on paper but aren't consistently implemented. The Director of Nursing's admission that nurses weren't present during showers when skin could be properly assessed reveals a systemic gap between policy and practice.
For a resident with multiple risk factors including thin skin, incontinence, and mobility issues, regular professional skin assessments are crucial for preventing painful and potentially dangerous pressure ulcers. Missing four weeks of required monitoring leaves vulnerable patients exposed to preventable complications.
The inspection was conducted as part of a complaint investigation, though the specific nature of the complaint that triggered the federal review was not detailed in the available records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care At Mount Pleasant from 2025-11-26 including all violations, facility responses, and corrective action plans.
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