Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards and policy for weekly skin evaluations and assessments for one resident. The facility's policy, titled 'Prevention and Treatment Overview,' mandates weekly skin integrity reviews to proactively identify changes in skin condition. However, a review of the resident's records revealed that only four skin checks were completed over a four-month period, contrary to the policy requirement of weekly documentation. The Director of Nursing (DON) acknowledged the oversight, stating that the skin checks should have been documented weekly but were not. The resident involved was admitted to the facility in 2013 and readmitted with diagnoses including wasting and atrophy, unspecified occlusion, and aphasia. During the period in question, the resident's records showed a knot on the forehead, which was noted in the limited skin assessments conducted. The DON confirmed that the facility missed the required weekly assessments and documentation, which should have been performed as per the facility's policy.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. F-842, Resident Records-Identifiable Information Element #1. Skin check for Resident #1 was completed and documented in the electronic medical record. No new areas of concern were identified. Element #2. Director of Nursing (DON) and/or designee conducted a full-house skin sweep on current residents to identify any new areas of skin. No new areas of concern were identified. Element #3. The Director of Nursing (DON) and/or designee will educate current licensed clinical staff on performing weekly skin checks on active residents and documenting findings in the electronic medical record timely and efficiently. Physicians and families will be notified of any newly identified skin and any new orders will be transcribed into the electronic medical record as indicated. Element #4. Director of Nursing (DON) and/or designee will audit the weekly skin checks for active residents in the electronic medical record every week for eight (8) weeks to ensure that the weekly skin checks are being performed timely. Results of the audits will be brought by the Nursing Home Administrator (NHA) or Director of Nursing (DON) and discussed at monthly Quality Assurance Performance Improvement meetings for review and recommendation for three months. Element #5. Facility's Allegation of Compliance Date is , 20205.