Failure to Complete and Document Required Skin Assessments and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that nursing services were provided in accordance with professional standards of quality, specifically regarding the implementation and documentation of skin assessments and adherence to physician orders for multiple residents. Several residents with significant cognitive impairments and high risk for pressure ulcers did not receive weekly skin assessments as ordered by their physicians. For example, one resident with severe cognitive impairment and high risk for pressure ulcers had only 8 weekly skin assessments documented over a 27-week period, despite a standing physician order for weekly checks. Similar deficiencies were found for other residents, where weekly skin checks were either missed or not documented in the electronic medical record, and there was no evidence of resident refusal or alternative documentation. In another instance, a resident was observed with a dressing on the lower right leg, but there was no corresponding physician order or documentation of the injury or treatment in the medical record. Nursing staff were unaware of the origin of the injury or the presence of a treatment order, and the DON confirmed that the expected protocol of assessment, physician notification, and obtaining treatment orders was not followed. Additionally, for a resident requiring a wrist splint, there was a physician order for pre- and post-use skin checks, but the clinical record did not contain any documentation of these assessments, and the resident reported that nursing staff did not check the skin under the splint. Interviews with nursing staff and the DON revealed an ongoing issue with the completion and documentation of required skin assessments. Staff acknowledged that physician orders for weekly skin checks were not consistently followed, and there was a lack of oversight due to recent changes in nursing leadership. The DON was aware of the deficiencies and confirmed that the facility had been experiencing problems with ensuring that nursing staff completed and documented skin checks as ordered.