Failure to Complete and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for one resident by not identifying a change in the resident's skin condition and not ensuring that weekly skin checks were completed as ordered. The resident, who had severe cognitive impairment, muscle weakness, osteoarthritis, thrombocytopenia, dementia, and protein-calorie malnutrition, was admitted with a Stage 1 pressure ulcer and multiple areas of purpura and bruising. Physician orders required weekly skin checks, but review of the medical record showed that these assessments were not documented after admission, and the last recorded skin assessment was on the day of admission. Nursing staff marked the Medication Administration Record as completed for skin checks, but no actual skin assessment details were documented. During a physical observation, the resident was found to have multiple bruises, open skin areas with dried blood, and discoloration on both lower extremities and wrists, which had not been previously reported to management or documented in the medical record. Certified Nursing Assistants stated they had reported the bruising and open skin areas to a nurse the previous day, but the Unit Manager and Director of Nurses confirmed that they were unaware of these findings and that the required skin assessments and documentation had not been completed. The physician and family had not been notified, and no investigation had been initiated regarding the new skin issues.