Failure to Monitor and Document Resident's Skin Lesion
Penalty
Summary
Facility staff failed to monitor and document changes in a resident's skin condition as required by facility policy. The resident, who had a history of stroke and aphasia but was assessed as cognitively intact, was identified as being at risk for skin impairment. Despite a care plan instructing staff to report and monitor changes in skin condition, a 5 cm dark lesion was noted on the resident's scalp. The resident expressed concern about the lesion through nonverbal cues, but there was no documentation of ongoing monitoring or follow-up in the clinical record after the lesion was initially identified. Staff interviews confirmed that the registered nurse was aware of the scalp lesion but did not monitor it, and the resident care manager was unaware of any further physician follow-up. Weekly skin audits and the treatment administration record did not reflect the presence or monitoring of the lesion. This lack of monitoring and documentation resulted in a failure to provide appropriate treatment and care according to the resident's needs and preferences.