Failure to Timely Assess and Document New Skin Condition
Penalty
Summary
The facility failed to ensure timely assessment and documentation of a new skin condition for a resident with dementia, anxiety, anemia, and type 2 diabetes mellitus, who required substantial assistance for mobility and transfers via mechanical lift. Despite observations by CNAs and nurses of a bruise on the resident's neck and jawline, there was no documentation in the electronic medical record (EMR) regarding the new skin concern from the time it was first noticed until several days later. Staff interviews revealed that the bruise was initially identified by a nurse and reported for follow-up, but no assessment or incident report was documented in the EMR as required by facility policy. The responsible RN assumed the previous shift would initiate the necessary documentation and did not complete an assessment or create an event in the EMR, resulting in a lack of monitoring and follow-up for the new skin condition. Observation by surveyors confirmed the presence of a bruise and a scab on the resident, and staff acknowledged the absence of timely documentation and assessment. The facility's policy required that any new skin alteration be documented with an incident report and progress note, with continued monitoring, but this was not followed. The deficiency was identified during a complaint survey, and the lack of documentation persisted until it was brought to the facility's attention by surveyors.