Failure to Complete Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to complete routine weekly skin assessments for one resident, as required by its own policy. The resident, who had diagnoses including dementia, fractures, incontinence, and impaired mobility, was care planned for impaired skin integrity and at risk for pressure ulcer development. Despite these risks and the care plan interventions specifying adherence to facility protocols for skin breakdown prevention, there was no documented evidence of skin assessments from 04/02/25 through 04/13/25. The last documented skin assessment was on 04/01/25, and the next was not until 04/13/25, when multiple bruises and areas of discoloration were observed and documented by nursing staff. Interviews with staff confirmed that weekly skin assessments were expected and that any changes in skin integrity should be reported immediately. However, the absence of documentation and delayed identification of bruising indicated that these assessments were not performed as required. The Corporate Quality Nurse confirmed the lack of documented assessments during the specified period and acknowledged that the bruising might have been identified sooner if the assessments had been completed as per policy.