Failure to Complete Weekly Skin Assessments per Care Plan
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for three residents by not completing weekly skin assessments as required. For one resident with a history of stroke, documentation showed that weekly skin inspections had not been completed since early May, despite a care plan directive for weekly assessments. Similarly, another resident with a stroke diagnosis had a care plan for weekly skin inspections, but records indicated that assessments were missed for several consecutive weeks. In both cases, staff interviews confirmed the absence of documentation to support that the required assessments were performed. A third resident, admitted with dementia, also had a care plan specifying weekly skin checks by a licensed nurse. However, documentation revealed that the weekly skin assessment was not completed as scheduled, and the Assistant Director of Nursing was unable to provide evidence that the assessment had occurred. These findings demonstrate that the facility did not follow through with the scheduled care plan interventions for weekly skin assessments for these residents.