Failure to Accurately Document Resident Skin Conditions on Monitoring Forms
Penalty
Summary
The facility failed to ensure that staff consistently and accurately documented observations of residents' skin issues and conditions on the designated skin monitoring forms. Certified Nursing Assistants (CNAs) were responsible for using the Skin Monitoring (SM): CNA Shower Review form to record skin observations during resident bed baths or showers, including noting specific skin issues and their locations. However, for two residents with documented wounds and pressure ulcers, the SM forms on multiple dates did not reflect the presence of these existing conditions, despite their persistence being noted in other clinical assessments and wound evaluation reports. Specifically, one resident had a wound on the right medial malleolus with serous drainage, and another had multiple pressure ulcers, including a Stage IV ulcer on the sacrum, as documented in comprehensive skin assessments and wound evaluation reports. On review, the SM forms for these residents failed to document these ongoing skin issues on several occasions. During interviews and record reviews, the Director of Nursing (DON) confirmed the omissions and was unable to provide a specific policy regarding CNA documentation of resident skin observations.