Failure to Complete Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to complete weekly skin assessments as ordered for three residents with non-pressure skin conditions. For one resident with peripheral autonomic neuropathy and protein-calorie malnutrition, the last documented skin assessment was several months prior to the survey, despite a physician's order for weekly assessments. Nursing staff confirmed that no recent skin evaluations were present in the medical record. Another resident with chronic obstructive pulmonary disease and moderate cognitive impairment was observed to have moderate white, dry flakes on the face and head. Although there was a physician's order for weekly skin assessments, the last documented assessment was several weeks prior. Nursing staff were unaware of any treatment orders for the skin condition and could not confirm how long the issue had been present. The DON acknowledged that weekly assessments were not being completed as ordered and that responsibility for these assessments had shifted among staff without proper follow-through. A third resident was observed with an open wound on the right lower leg. Although there was a physician's order for weekly skin assessments and documentation of findings, there were no weekly assessments recorded for over two months. The DON and nursing staff identified a system error that resulted in the failure to generate and complete the required assessments after the departure of the wound care nurse. Review of shower sheets completed by CNAs did not document the resident's current wound, and staff interviews confirmed a lack of proper skin assessment documentation during the relevant period.