Incomplete and Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident when a licensed vocational nurse (LVN) did not properly document a skin assessment following an altercation. The resident, who had diagnoses including dementia and severely impaired cognition, was involved in an incident where he was struck in the face by another resident, resulting in a superficial scratch on the bridge of his nose and redness to his left cheek. Documentation inconsistencies were noted: the LVN's weekly skin evaluation stated there were no abnormal skin areas or wounds, despite other records and interviews confirming the presence of a scratch that required treatment with triple antibiotic ointment. Interviews with the LVN, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed the presence of the abrasion and the need for accurate documentation. The facility's own documentation policy requires that each resident's medical record accurately reflect the resident's experiences and include complete, accurate, and timely information. The failure to document the skin injury as observed and treated resulted in incomplete and inaccurate clinical records for the resident.