Missed Weekly Skin Assessments for Cognitively Impaired Resident
Penalty
Summary
The facility failed to conduct weekly skin assessments for one resident during two consecutive weeks, as required by both facility policy and the resident's care plan. The resident in question was an elderly male with multiple diagnoses, including Alzheimer's disease, chronic kidney disease stage 3, muscle wasting, and impaired coordination. He was severely cognitively impaired and required moderate assistance with activities of daily living. Despite being care planned for risk of pressure ulcer development and receiving hospice services, there were no documented weekly skin assessments for the specified periods. Interviews with nursing staff, the DON, and the administrator confirmed that all residents were expected to receive weekly skin assessments, and that it was the responsibility of the nursing staff to complete them. Both the DON and the administrator were unaware that the assessments had not been completed for the resident during the identified weeks. The facility's policy also required weekly skin assessments to be documented in the EMR, which was not done for the resident during the deficiency period.