Failure to Perform and Document Weekly Skin Assessments and Notify Providers
Penalty
Summary
The facility failed to ensure that weekly skin assessments were performed, documented, and acted upon as required for two residents reviewed for non-pressure skin issues. For one resident, multiple bruises on both arms were observed on several occasions, but there were no physician orders to monitor the bruising, and weekly skin assessments either were not completed as ordered or failed to identify the bruises. The care plan instructed staff to perform weekly head-to-toe skin assessments and to notify the nurse supervisor of any skin breakdown, including bruises, but this was not followed. Staff interviews confirmed that weekly skin checks were missed and that new skin issues were not documented or reported as required. For another resident, a scab with bloody drainage was observed on the left cheek during multiple observations, but there was no treatment order in the record and weekly skin assessments had not been completed after a certain date. The resident's care plan and physician orders required weekly skin checks, but staff failed to perform and document these assessments, and did not notify the physician about the new skin issue. Staff interviews confirmed that the required assessments and notifications were not completed according to facility policy and physician orders.