Missed Weekly Skin Checks for Resident with Fragile Skin
Penalty
Summary
Facility staff failed to provide resident-centered care and treatment in accordance with professional standards of practice by not completing scheduled weekly skin care evaluations for one resident with fragile skin, as required by the resident's care plan and facility policy. The care plan, revised in November 2024, specified weekly skin checks due to the resident's propensity for bruising and skin tears, and the Treatment Administration Record (TAR) showed standing orders for these checks. However, documentation revealed that on two separate occasions, the weekly skin checks were not performed, with staff noting the resident was sleeping as the reason for omission. Interviews with facility staff, including a Registered Nurse, Resident Care Manager, and Director of Nursing, confirmed that the expectation was for weekly skin checks to be completed as per the care plan. The staff acknowledged that the checks were missed and that the nurse should have either attempted the check at another time or communicated the need to the next shift. The lack of documentation and failure to perform the required skin assessments constituted a deviation from both facility policy and the resident's individualized care plan.