Failure to Document Weekly Skin Assessments per Facility Policy
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards for one resident reviewed for record accuracy. Specifically, the facility did not ensure that weekly skin evaluations were documented as required by facility policy for six out of seven weeks during a specified period. Although the Medication Administration Record (MAR) indicated that weekly skin evaluations were marked as completed, a review of the actual assessment documentation revealed that these evaluations were not performed or recorded for the majority of the required dates. Interviews with nursing staff and the Director of Nursing (DON) confirmed that weekly skin assessments were not conducted or documented during the months in question. The resident involved was an elderly female with a history of muscle wasting, urinary tract infections, and mild cognitive impairment, and was identified as being at risk for pressure ulcer development. The resident's care plan included interventions for monitoring skin integrity, and facility policy required weekly skin and wound assessments by a licensed nurse. Despite these requirements, the necessary documentation was missing, and staff interviews indicated a lack of consistent practice and understanding regarding the completion and documentation of weekly skin assessments.