Incomplete Medical Record Documentation for Resident Skin Assessment
Penalty
No penalty information released
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Summary
The facility failed to ensure complete and accurate medical record documentation for one resident. The resident, who had a history of metabolic encephalopathy and a left below-the-knee amputation, was admitted with skin assessments indicating intact skin and no open areas. However, the resident later reported to a nurse practitioner that a bandaged area on the right lower extremity had not been changed or assessed by staff since admission. Upon assessment, a treatment was prescribed for the area. There was no documentation in the clinical record that staff had identified or assessed the impaired area from admission until eight days later.