Failure to Complete and Document Weekly Skin Assessments per Policy
Penalty
Summary
The facility failed to complete skin assessments per its own policy and standards of practice for one resident with a notable wound and high risk for skin breakdown. The facility policy required weekly skin assessments for residents with wounds or high Braden scores, and documentation of any alterations in skin integrity using a standardized method. For the resident in question, who had chronic kidney disease and actinic keratosis and was cognitively intact, a discolored area was observed on the right cheek. The area was initially documented with measurements, but subsequent documentation was missing for a period exceeding one week, and later entries lacked required measurements. Interviews with staff confirmed that the resident had been self-administering a steroid cream and staff were applying urea cream, both of which were discontinued after the discoloration developed. The Director of Nursing acknowledged that there was a gap in documentation from the initial assessment to the next entry, which was longer than the weekly interval required by policy, and that some later assessments did not include measurements. These actions and omissions resulted in the facility not following its own protocols for skin assessment and documentation.