Failure to Perform and Document Weekly Skin Evaluations
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including anemia, diabetes mellitus, chronic kidney disease, and congestive heart failure, did not receive weekly skin evaluations as required by facility policy. The resident was assessed as having moderately impaired cognition, was always incontinent of bowel and bladder, and was at risk for skin integrity issues, with an actual stage III pressure ulcer present. The care plan specified weekly body audits, but clinical documentation showed that skin evaluations were inconsistently performed, with several weeks and an entire month lacking any documented assessments. There was no evidence in the nursing notes that the resident refused these evaluations during the period in question. The Director of Nursing confirmed that weekly skin checks should have been completed and documented in the electronic medical record, and that refusals should be recorded and communicated to the provider. However, the facility was unable to provide documentation for multiple missed weeks, and the undated facility policy required both daily skin checks by Certified Nursing Assistants and routine checks by licensed nursing personnel. The failure to perform and document weekly skin evaluations as per policy led to the identified deficiency.