Failure to Document and Complete Physician-Ordered Skin Assessments
Penalty
Summary
The facility failed to meet professional standards of quality by not ensuring that weekly skin assessments ordered by physicians were completed and documented for two residents. For one resident admitted with altered mental status and a history of falls, a physician's order required weekly skin evaluations with documentation under observations. Although the Medication Administration Record (MAR) indicated that the assessment was completed, there was no evidence in the weekly skin evaluation observations or progress notes to confirm that the assessment was actually performed on the specified date. Similarly, another resident admitted with Parkinson's Disease, dementia, and a nasal bone fracture had a physician's order for weekly skin evaluations. The MAR showed that these assessments were signed off as completed on two occasions, but a review of the weekly skin evaluation observations and progress notes did not provide evidence that the assessments were conducted or documented as required. During an interview, the Director of Nursing Services was unable to provide documentation to support that the assessments had been completed per the physician's orders.