Failure to Implement Weekly Skin Evaluations per Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan as developed for a resident with skin impairment related to moisture-associated skin damage. The care plan, initiated in April 2025, required staff to monitor and document weekly skin evaluations, as well as to follow physician orders for weekly skin assessments every Wednesday. However, a review of the resident's records revealed that these weekly evaluations were not completed or documented during April 2025, with at least one scheduled assessment not initialed as completed. The facility's policy mandates the development and implementation of a comprehensive, person-centered care plan with measurable objectives and time frames, which was not adhered to in this case. Interviews with facility staff, including the DON, the charge nurse, and the MDS nurse, confirmed that the weekly skin evaluations were not performed as required by the care plan. The charge nurse acknowledged her responsibility for completing the evaluations and admitted to not following the care plan. The MDS nurse emphasized that the care plan is intended to guide staff in delivering care and confirmed that the resident could not receive quality care if the care plan was not followed. The resident in question was severely cognitively impaired and had a history of chronic ulcers and atherosclerosis with ulceration, further underscoring the need for consistent skin monitoring.