Failure to Document Weekly Skin Integrity Assessments for High-Risk Resident
Penalty
Summary
The facility failed to ensure ongoing assessment and documentation of skin integrity for a resident at high risk for skin breakdown. According to facility policy, a licensed nurse is required to complete and document a total body skin evaluation weekly for each resident. However, for one resident with a history of contractures and a stage 3 pressure ulcer, the Weekly Skin Integrity Review was only documented once, with no further weekly assessments recorded as required. This lapse occurred even after a QAPI intervention was initiated, and the lack of documentation persisted. Interviews with the DON confirmed that the facility was aware of the missed reviews but did not effectively implement the QAPI plan, resulting in continued failure to document weekly skin checks for the high-risk resident. The NHA also acknowledged that the facility did not follow through with its internal corrective strategies. The resident in question had severely impaired cognition and required ongoing wound care for a stage 3 pressure ulcer, as indicated by physician orders and clinical records.