Incomplete and Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident's skin assessment. During a record review, it was found that the physician's orders, care plan, weekly skin assessments, and progress notes did not indicate any skin concerns for the resident, except for a documented skin tear on the right hand. However, a Nursing Assistant Skin Inspection and Shower sheet indicated a skin concern on the bilateral buttocks, which was not reflected elsewhere in the resident's medical record. The Director of Nursing and a Corporate RN confirmed that there was no other documentation of this skin issue and believed the entry may have been made in error for the wrong resident, as all other weekly skin observations before and after the date in question showed no indication of skin concerns.