Failure to Assess and Document Resident's Skin Issue
Penalty
Summary
A resident with a sore and redness near the right eye reported pain and uncertainty about the cause, stating he may have scratched himself due to lack of hand control. The resident indicated he had informed someone about the wound, but was unsure who, and stated that nursing staff had not examined the area as of the interview date. The Director of Nursing was unaware of any skin issue for this resident and stated that such concerns should be reported to a nurse and documented on shower sheets. The Assistant Director of Nursing later confirmed the presence of a scratch near the resident's eye, noting that if a Certified Nurse Aide observed it, it should have been documented and reported. Review of the resident's shower sheets over multiple dates revealed no documentation of the skin issue, indicating a lack of assessment, documentation, and treatment for the resident's skin condition.