Failure to Identify and Document Skin Changes and Complete Weekly Skin Checks
Penalty
Summary
The facility failed to ensure proper identification and documentation of skin changes for two residents, resulting in deficiencies in the standard of care. For one resident with diagnoses including depression, diabetes, and dementia, staff did not identify or document a visible bruise on the right forearm during weekly skin checks, despite multiple observations by surveyors and staff interviews confirming the presence of the bruise. The resident was dependent on staff for daily care and had a care plan requiring regular skin checks and reporting of skin changes. However, weekly skin assessments repeatedly documented the skin as intact, and staff failed to report or document the bruise, even after it was observed by several staff members and the surveyor. For another resident with Alzheimer's disease and severe cognitive impairment, a skin tear was observed on the right arm, but the injury was not documented on the skin check as required. The resident was known to have fragile skin and was at high risk for skin tears, with protective measures in place. Despite this, the skin tear was not recorded during the skin assessment, and staff interviews revealed that the injury could have been missed if protective sleeves were worn. Additionally, the resident's medical record showed that weekly skin checks were missed on four occasions over two months, contrary to physician orders and facility policy. Interviews with nursing staff and the Director of Nursing confirmed that all skin impairments should be documented and reported, and that weekly skin checks are expected to be completed as ordered. The Director of Nursing was unaware of the missed skin checks and stated that any observed skin area should be included in the weekly documentation. The failure to identify, document, and report skin changes and to complete weekly skin checks as ordered led to the deficiencies cited in the report.