Failure to Document Weekly Skin Assessments for At-Risk Residents
Penalty
Summary
The facility failed to ensure that weekly skin assessments were documented for two residents who were at risk for skin integrity issues. For one resident with a history of stroke, hemiplegia, incontinence, diabetes, and impaired mobility, the care plan required weekly skin checks and other interventions to prevent skin breakdown. However, there was no documentation of weekly skin observation tool assessments for this resident between February and late June, despite the resident being identified as very high risk for pressure sores on the Braden scale. The only documented skin assessments during this period were at the beginning and end of the timeframe, with a gap of several months in between. Similarly, another resident with chronic ulcer, osteomyelitis, and a history of stroke was also identified as at risk for skin breakdown, with care plan interventions including regular Braden/Norton assessments. For this resident, there was no documentation of weekly skin assessments between late April and mid-July, except for assessments at the start and end of the period. The Director of Nursing confirmed that she could not provide documentation of the required weekly skin assessments for either resident during the specified periods, despite facility policy directing that weekly head-to-toe skin checks be completed and documented.