Failure to Document Weekly Skin Checks for Resident with Pressure Injuries
Penalty
Summary
Facility staff failed to document a weekly skin check for one resident over a two-week period, despite the resident being dependent on staff for all activities of daily living and having multiple pressure injuries and Moisture-Associated Skin Damage (MASD) upon readmission. The resident's medical record and progress notes confirmed the absence of a weekly wound note from 7/5/2025 to 7/18/2025, which was required by facility policy for tracking the progress or decline of skin conditions. The treatment nurse, who was responsible for completing the weekly wound note, acknowledged missing the documentation during this period. The facility's policy and procedure specified that weekly skin checks must be conducted by a licensed nurse and documented in the electronic medical record, but this was not done for the resident in question.