Failure to Follow Physician Orders for Skin Assessment and Documentation
Penalty
Summary
The facility failed to follow physician orders for skin assessments and monitoring for two residents with non-pressure skin conditions. For one resident with chronic pain and depression, a physician order required staff to check the resident's skin and document any new conditions with a progress note and a skin documentation form. Despite the presence of a bruise on the resident's right upper forearm observed over several days, there was no assessment, monitoring, or documentation in the health record. Staff confirmed the absence of documentation and acknowledged that the expected procedures were not followed. For another resident with Type 2 Diabetes and vascular disease, a similar physician order was in place for skin checks and documentation of new conditions. The resident was observed with discoloration and scabbing on the left foot, but the health record contained no assessment, monitoring, or progress note regarding these findings. Staff confirmed the presence of the skin condition and the lack of documentation. Facility leadership acknowledged that the required assessments and documentation were not completed for both residents.