Failure to Consistently Complete and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that weekly skin assessments were consistently completed for two residents, as required by physician orders and facility policy. For one resident with diagnoses including amyotrophic lateral sclerosis, subdural hemorrhage, malnutrition, and dysphagia, the care plan and physician orders specified weekly skin assessments to be documented every Sunday evening. However, review of the electronic medical record revealed that several weekly assessments were not documented during the review period, excluding the weeks the resident was hospitalized. The resident, who was cognitively intact but dependent on staff for mobility and care, was unable to confirm when her skin was last assessed. Another resident, with a history of atherosclerotic heart disease, chronic heart failure, fibromyalgia, muscle weakness, and dementia, also had a care plan and physician order for weekly skin assessments every Tuesday evening. The record review showed that multiple weekly assessments were missing during the review period. This resident was moderately cognitively impaired, required substantial assistance with mobility and hygiene, and was always incontinent of bowel and bladder, placing her at risk for skin breakdown. Staff interviews confirmed that weekly skin assessments were expected and that documentation should occur in the electronic medical record. However, it was noted that nurses appeared to rely on a paper schedule rather than electronic alerts, which may have contributed to missed assessments. Both the regional clinical consultant and nursing staff acknowledged the missing documentation for the two residents.