Failure to Document Weekly Skin Assessments for MASD
Penalty
Summary
The facility failed to implement the care plan for a resident who was admitted with multiple diagnoses, including diabetes mellitus, difficulty in walking, and dementia, and who had moisture associated skin damage (MASD) on the buttocks. The care plan required weekly assessment and documentation of the MASD, including measurements and observations of the affected area. However, there was no documentation that these weekly assessments were completed as required by the care plan and facility policy. Record reviews and staff interviews confirmed that while daily treatments for the MASD were documented, there was no evidence of weekly skin assessments or documentation of the MASD's status or progress. The lack of documentation made it impossible to determine whether the MASD had healed prior to the resident's discharge. The facility's policy required licensed nurses to document the status of all skin conditions at least weekly, but this was not done for this resident.