Failure to Complete and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that weekly skin assessments were completed and documented as ordered by the physician and in accordance with facility policy for one resident with a history of skin conditions. Facility policy required a full body skin assessment by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. However, a review of the resident's records revealed that weekly skin evaluations were not completed or documented during April, despite physician orders and facility policy. The resident, who was severely cognitively impaired and had a history of chronic ulcers and atherosclerosis, developed moisture-associated skin damage to the buttocks, which was not consistently documented in the weekly skin reports. Interviews with the DON and the responsible RN confirmed that the weekly skin evaluations were either not performed or not entered into the electronic record, with the RN admitting to recording results on scratch paper and failing to transfer them to the computer. The DON stated that lack of documentation indicates the task was not completed. Observations confirmed the presence of healed and open areas on the resident's buttocks, and treatment for the open area had been initiated, but the required weekly assessments were missing from the records for the specified period.