Failure to Accurately Document Skin Assessment Findings
Penalty
Summary
A deficiency occurred when a resident with a history of cognitive communication deficit, dementia, and risk for pressure ulcers did not receive an accurate skin assessment as required by professional standards and the facility's policy. On the date in question, the resident's weekly skin assessment was documented as having no new skin integrity issues by a TN. However, direct observation revealed multiple small red scratch-like marks under both of the resident's eyes, which were not documented in the assessment. The resident was unable to be interviewed due to severe cognitive impairment. When the LVN was shown the resident, she acknowledged the presence of scratch marks and stated that such findings should be documented in a skin assessment. The TN who completed the assessment admitted she did not document the scratches, explaining she typically only records issues that require treatment, such as skin tears or open areas. The DON confirmed that scratches should be documented as they represent a break in the skin and could worsen. The facility's policy requires a head-to-toe skin assessment, including documentation of any redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions.