Incomplete Documentation of Skin Assessments and Treatments
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with a history of acute kidney failure and moderate cognitive impairment, specifically in the area of skin condition management. The resident's care plan included interventions for monitoring skin integrity and treating a diagnosis of candidiasis, with instructions for regular skin assessments and topical medication administration. However, documentation in the electronic medical record showed that several scheduled weekly skin assessments were not recorded as completed on specific dates. Interviews with LPNs revealed that while some assessments were performed, the staff failed to document them due to being busy or forgetting. Additionally, the resident's treatment administration records for a prescribed steroid cream indicated multiple instances where there was no documentation of the treatment being administered as ordered. Several LPNs confirmed in interviews that they had provided the treatments but neglected to sign off on the treatment administration records after completion. Both the Regional Nurse Consultant and the Administrator acknowledged that all assessments and treatments should have been documented in a timely manner, but this was not consistently done.