Failure to Complete Weekly Skin Assessments per Physician Orders
Penalty
Summary
The facility failed to complete weekly skin assessments as ordered by physicians for three residents with significant risk factors for skin breakdown and wounds. For one resident with diagnoses including cellulitis, rheumatoid arthritis, and chronic pain syndrome, a physician's order required weekly body audits on shower days. While one audit was documented, subsequent weekly audits were missing for several weeks. During this period, the resident developed multiple skin impairments, including an open foot ulcer and cellulitis, which were only identified after a significant lapse in weekly assessments. The care plan addressing skin breakdown risk factors was not updated until well after the impairments were identified and after the resident's passing. Another resident with a history of subarachnoid hemorrhage and epilepsy was also subject to a physician's order for weekly body audits. Documentation showed that after an initial audit, no further weekly audits were recorded for several months, despite the resident developing pressure ulcers on the right lateral foot and ankle. Nursing notes and the wound tracker confirmed that these wounds remained unhealed and required ongoing wound care, yet there was a lack of consistent weekly documentation as required by the physician's order and facility policy. A third resident, diagnosed with dementia, diabetes, peripheral vascular disease, and neuropathy, also had a physician's order for weekly body audits. The clinical record revealed no completed weekly audits for an extended period, during which the resident developed a diabetic wound on the right second toe. Nursing documentation of skin assessments was absent until weeks after the wound was identified. Interviews with facility staff confirmed that weekly skin audits were expected per physician orders and facility policy, but these were not consistently performed or documented for the residents in question.