Failure to Document Weekly Skin Assessment as Required by Policy
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically by not ensuring that a weekly skin assessment was documented in accordance with facility policy. The resident in question was an older male with a history of nephrostomy tube malfunction, bilateral hydronephrosis, left hydroureter, and displacement of a left percutaneous nephrostomy tube. His care plan included interventions for risk of impaired skin integrity and required weekly skin checks. However, review of July 2025 records showed no skin assessment was completed for the week of 07/21-07/25. Interviews with nursing staff revealed that the assigned LVN did not document the required weekly skin assessment, initially stating it was not done because a previous assessment had been completed a few days earlier, and later admitting to having performed but not documented the assessment. Another LVN also failed to complete the scheduled weekly assessment, believing an incident-related assessment was sufficient. The DON confirmed that while weekend audits were being conducted, there was no quality assurance process in place to verify completion of weekly skin assessments. The facility's documentation policy required objective observations and treatments to be recorded, but this was not followed in this instance.