Failure to Timely Document Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that weekly skin checks were documented in a timely manner for one resident. The resident, who had diagnoses including heart failure, diabetes mellitus, and cellulitis, was at risk for developing pressure ulcers and required partial to moderate assistance with activities of daily living. Although weekly skin assessments were indicated as performed on specific dates, the documentation for these assessments was not created until several weeks later, based on the nurse's recollection rather than contemporaneous observation. During interviews, the LVN acknowledged that the documentation for multiple weekly skin checks was entered retrospectively, relying on memory rather than immediate charting. The Director of Nursing confirmed that skin assessments should be documented on the same day to ensure accuracy and admitted there was potential for inaccuracy in the records. Facility policies required that resident health records be current, accurate, and timely, and that licensed nurses document weekly skin assessments and the effectiveness of treatments. The failure to document skin checks promptly resulted in the potential for inaccurate information to be communicated among healthcare providers and could delay necessary care or interventions.