Failure to Document Weekly Skin Assessments in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for two residents were maintained in accordance with accepted professional standards and practices. Specifically, required weekly Skin & Wound- Total Body Skin Assessments were not documented in the electronic medical record (EMR) for multiple weeks, despite being marked as administered in the Licensed Nurse Administration Records. For one resident, five weekly assessments were missing from the medical record, and for another resident, three weekly assessments were not recorded. There was no alternative documentation found in the residents' progress notes for the missing assessments. Both residents had significant medical histories, including conditions such as hemiplegia, cerebral aneurysm, multi-system degeneration, and Parkinsonism, and required varying levels of assistance with mobility. Orders were in place for weekly skin assessments to monitor for pressure injuries and other skin concerns. Interviews with staff revealed that while the assessments were scheduled and reminders were present in the EMR, the actual documentation of the assessments was inconsistent. Some staff believed that checking off the order in the administration record was sufficient, while others indicated that assessments might have been completed but not properly documented. The facility's policy required licensed nurses to conduct and document weekly skin assessments in the resident's medical record. However, the process for ensuring completion and documentation was not consistently followed. Staff interviews indicated a lack of clarity regarding where and how to document the assessments, and there was reliance on other forms of skin monitoring, such as daily care by CNAs and nurses, but without the required weekly documentation in the medical record. This resulted in incomplete clinical records for the affected residents.