Failure to Identify and Document Skin Alterations During Assessments
Penalty
Summary
Licensed nurses at the facility failed to perform skin assessments with the necessary knowledge, skills, and competencies, as required by facility policy. Specifically, for seven out of twenty-eight licensed nurses, there were deficiencies in identifying and documenting skin alterations during weekly assessments. In the case of one resident with chronic heart failure and chronic kidney disease, weekly skin assessments repeatedly documented no skin alterations, despite a physician's order for dermatology evaluation and a nurse's progress note later identifying a large growth on the resident's right cheek that had not been previously documented. The facility's policy required weekly skin assessments by nurses and prompt reporting of any changes by CNAs to the nursing staff. However, the growth on the resident's cheek was not identified or documented during multiple weekly assessments, and the physician was not notified in a timely manner. The Director of Nursing confirmed that the growth should have been detected, documented, and reported by the licensed nursing staff, but this did not occur.