Failure to Accurately Document Residents' Skin and Toenail Conditions
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents by not documenting their skin, toe, and toenail conditions in the Nursing Weekly Summary (NWS). For one resident with right-sided paralysis, observations revealed red, swollen, and thickened yellow toenails, as well as long and discolored toenails on both feet. Despite these findings, the NWS for several weeks indicated that the resident's skin was clear and intact, with no new skin issues documented. Staff interviews confirmed that the resident's toe and toenail conditions were not addressed or recorded in the NWS, even though podiatry notes indicated ongoing issues such as dystrophic and thickened nails with onychomycosis. Another resident was observed to have deformed, thick, long, and discolored toenails with a fungus-like appearance, as well as dry and ashy skin on the toes. The resident reported pain in the toenails. The podiatry evaluation documented nail dystrophy, fungal infection, and hammer toe deformities. However, the NWS for this resident consistently documented only moisture-associated skin damage (MASD) in the peri and sacrococcygeal areas, without any mention of the condition of the feet, toes, or toenails. Staff acknowledged that these conditions should have been included in the nursing assessment and documented in the medical record. The facility's policy required nurses to record information related to changes in a resident's condition or status in the medical record. Despite this, the observed and documented conditions of the residents' feet and toenails were not reflected in the NWS, resulting in incomplete and inaccurate medical records for both residents.