Failure to Document Weekly Skin Assessments in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, weekly skin assessments for a male resident with diagnoses including type 2 diabetes mellitus, muscle weakness, and dysphagia were not documented for two separate weeks. The resident was identified as being at risk for pressure ulcers, and his care plan required weekly monitoring and documentation of skin integrity. Review of the electronic medical record and progress notes confirmed the absence of required weekly skin assessments for the specified weeks, and no alternative documentation was found to explain the omission. Interviews with the treatment nurse and the DON revealed that both floor nurses and the treatment nurse shared responsibility for completing and documenting weekly skin assessments. The DON confirmed that if an assessment was not documented, it was considered not to have occurred, and she was unable to locate the missing assessments. The facility's policy required weekly head-to-toe skin checks by a licensed nurse, with findings documented accordingly, but this was not followed for the resident in question during the identified weeks.