Failure to Perform Ongoing Skin Assessments and Documentation
Penalty
Summary
A resident with multiple complex medical conditions, including metabolic encephalopathy, dementia, and a history of falls, was admitted with existing skin impairments such as a scalp scab and bilateral upper extremity bruises. Initial assessments and skilled documentation noted these skin issues for several days following admission. However, after a certain date, there were no further skilled notes or documentation regarding the resident's skin condition, and no weekly skin checks were performed as required. The resident's care plan identified a risk for skin impairment and included interventions such as monitoring and observing the skin during routine care and notifying a nurse of any concerns. Despite these interventions, the facility failed to continue regular skin assessments and documentation after the initial period. The facility's own policies required ongoing skin monitoring, documentation of changes, and communication among the care team, but these procedures were not followed for this resident.