Failure to Document Weekly Skin Assessments for At-Risk Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by not documenting weekly skin assessments as required. For one resident with severe cognitive impairment and significant physical assistance needs, there was no evidence of weekly skin inspections for multiple weeks, despite the resident being at risk for pressure ulcers and having no current skin issues. Another resident, who was cognitively intact but required substantial assistance and had stage 4 pressure ulcers, also lacked documentation of weekly skin assessments for several weeks, even though wound care orders and a care plan were in place for her pressure ulcers. A third resident, also with severe cognitive impairment and high risk for pressure ulcers, did not have weekly skin assessments documented for an extended period, despite her care plan indicating the need for extensive assistance and monitoring for potential pressure ulcer development. Observations and interviews confirmed that staff performed skin checks during care activities, and CNAs completed shower sheets, but these assessments were not consistently documented in the electronic medical record as required by facility policy. Interviews with nursing staff, the ADON, DON, and the administrator revealed that charge nurses were responsible for completing and documenting weekly skin assessments in the electronic system. However, changes in the electronic medical record system and competing duties contributed to missed documentation. The DON and ADON acknowledged the failure to document, attributing it to system updates and workflow challenges, but maintained that skin assessments were being performed even if not recorded.