Failure to Complete and Document Weekly Skin Assessments and Wound Treatments
Penalty
Summary
Facility staff failed to meet professional standards by not completing and documenting weekly skin assessments and physician-ordered wound treatments for three residents out of a sample of six. The facility's policy required licensed or registered nurses to conduct full body skin assessments upon admission and weekly thereafter, as well as after any change in condition or new pressure injury. However, medical record reviews revealed multiple weeks where no documentation of these assessments was present for the affected residents. The residents involved had significant medical histories, including diagnoses such as stroke, pressure ulcers, chronic non-pressure ulcers, Parkinson's disease with dyskinesia, and immobility, all of which increased their risk for skin breakdown. Physician orders for these residents included specific wound care treatments and the use of barrier creams, which were to be documented on the Treatment Administration Record (TAR). Review of the TARs showed numerous dates where staff did not document that wound care was provided as ordered. Interviews with nursing staff, the DON, and the Administrator confirmed that weekly skin assessments and wound care documentation were expected responsibilities. Staff acknowledged that missing documentation on the TAR typically indicated that treatments were not completed. The DON admitted awareness of lapses in completing skin assessments but was not aware of the extent of missing documentation for wound care treatments.