Incomplete Documentation of Resident Skin Condition
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete, specifically regarding the assessment and documentation of a skin condition. The resident, who had multiple diagnoses including dementia and diabetes, was admitted with orders for weekly skin checks. On the day the resident was found on the floor and subsequently sent to the hospital for evaluation of a possible infection and cellulitis on the left arm, there was no nursing assessment or description of the skin condition documented in the clinical record. Interviews with staff revealed that a CNA observed an inflamed and purple area on the resident's arm but did not report it to a nurse, assuming everyone was already aware. A registered nurse recalled noticing a red, swollen, and open area on the resident's arm the day before the hospital transfer, and stated that the area worsened by the following day, prompting treatment and wrapping of the arm. However, this assessment and treatment were not documented in the resident's medical record. A unit manager and LPN stated that the weekly skin assessment was completed after the resident had already been sent to the hospital, and that the assessment inaccurately indicated no new or ongoing skin issues. The facility's policies require that all changes in a resident's condition, including skin abnormalities, be documented in the medical record with specific details. The Director of Nursing confirmed that assessments should be completed timely and documented accurately, and that it would be inappropriate to document an assessment that was not actually performed.