Failure to Complete Required Skin Checks, Equipment Monitoring, and Baseline Assessments
Penalty
Summary
Multiple deficiencies were identified in the facility's provision of care, specifically related to the failure to ensure that services met professional standards of quality. Several residents with significant risk factors for skin breakdown, including severe cognitive impairment, immobility, and high or moderate risk scores on the Norton Scale, did not receive weekly skin checks as ordered by their physicians and as required by facility policy. In several cases, the electronic medical record (EMR) system upgrade was cited as a reason for missed or unscheduled assessments, but staff interviews confirmed that the expectation was for weekly skin checks to be completed regardless of EMR issues. Documentation for these assessments was missing for multiple weeks for several residents, and in one case, a skin check was started but left incomplete and unsigned. One resident, who was dependent for all functional tasks and at high risk for pressure ulcers, did not have weekly skin checks completed for four consecutive weeks. Another resident, also at high risk, missed several weekly skin checks over a two-month period. A third resident, with moderate risk for pressure ulcers, had no physician order for weekly skin checks and missed two scheduled assessments. Staff interviews confirmed that all residents at risk should have weekly skin checks and appropriate physician orders, and that the lack of completed assessments was not justified. Additional deficiencies included the failure to ensure that a resident's air mattress, used for pressure ulcer prevention, was functioning. The air mattress was observed to be deflated and non-functional on multiple occasions, and there was no physician order or care plan documentation for its use or settings. Staff acknowledged that the lack of an order contributed to the failure to check the mattress function regularly. Furthermore, for a resident started on an antipsychotic medication, the required baseline AIMS (Abnormal Involuntary Movement Scale) assessment was not completed upon admission or at the initiation of the medication, despite pharmacy recommendations and staff acknowledgment of the requirement.