Failure to Document Nursing Assessment After Skin Changes
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including syncope, muscle weakness, gait abnormalities, bilateral knee replacements, and schizophrenia, did not receive nursing assessments related to changes in skin integrity documented in the medical record. The resident was at risk for pressure ulcers, required substantial assistance for mobility and transfers, was always incontinent, and used a wheelchair independently. Orders were received for a low-air loss mattress and barrier cream due to observed redness and open areas on the resident's coccyx and left buttocks, as noted on a shower sheet completed by a CNA and a nurse. Despite the CNA documenting the presence of two open areas on the resident's body map and reporting these findings, there was no corresponding nursing assessment or documentation in the resident's medical record regarding these skin changes. Interviews with staff confirmed that while the CNA reported the findings to the treatment nurse, and the DON expected a change in condition form and further assessment, no such documentation or assessment was completed. The only documentation present was related to the application of barrier cream and dressing, not a full nursing assessment of the wounds. Facility policies required licensed nurses to conduct and document pressure injury risk assessments and full skin assessments whenever a resident's condition changed or a new skin issue was identified. The lack of documentation and assessment by licensed nursing staff following the identification of new open areas on the resident's skin constituted a failure to meet professional standards of quality care, as required by facility policy and procedure.