Failure to Accurately Assess and Document Skin Excoriation
Penalty
Summary
The facility failed to ensure the accuracy of assessments for a resident with a history of hemiplegia, diabetes mellitus, and failure to thrive, specifically regarding an area of excoriation on the resident's left buttock. Documentation in the resident's records, including the Admission Record, Care Plan, Treatment Administration Record, and Progress Notes, indicated the presence of excoriation and the need for monitoring for signs of infection. However, the Nursing Admission Assessment did not include measurements or detailed information about the skin condition, and subsequent documentation lacked specifics on the progression or changes in the excoriation. Interviews with facility staff, including an LVN and the DON, confirmed that while the excoriation was a known and ongoing issue, assessments and documentation did not consistently include details such as measurements, appearance, or progression of the wound. The DON stated that expectations for skin documentation included appearance, stage, measurements, progression, odor, and drainage, but these elements were not present in the records reviewed. This lack of detailed and accurate assessment resulted in an inability to monitor the progression of the resident's skin condition and determine if it was improving or worsening.