Failure to Complete Comprehensive Skin Assessments and Documentation
Penalty
Summary
The facility failed to ensure comprehensive skin assessments were completed for three residents who required services meeting professional standards. For one resident with multiple chronic wounds on admission, there was no documentation of wound measurements or characteristics on weekly skin evaluations after the initial assessment, and no skin evaluations were completed following hospitalizations for cellulitis and skin tears. Staff interviews confirmed that nurses were expected to document wound location, measurements, characteristics, and notify providers of changes, but this was not consistently done. Another resident with skin conditions in the abdominal folds, groin, and under the breasts reported that prescribed treatments were not administered as ordered, and documentation lacked details about a coccyx wound and the characteristics of skin conditions. The DON was unaware of the coccyx wound and acknowledged possible incomplete documentation of care and treatment refusals. A third resident had a wound care order, but skin evaluations did not document the wound or its characteristics, and a new skin tear was not measured or described until the wound management company became involved. Staff interviews revealed confusion about proper documentation and incomplete use of skin evaluation forms.