Failure to Complete and Document Weekly Skin Checks for Two Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding the completion of weekly skin checks for two residents. For one resident with multiple diagnoses including vascular dementia, chronic kidney disease, and diabetes, physician orders required weekly skin checks. However, review of the electronic medical record revealed only one documented skin evaluation during the resident's stay, despite the presence of scratches and dried blood on the arms. Additionally, there was no care plan addressing skin integrity or weekly skin checks for this resident. Interviews with nursing staff and the acting DON confirmed that weekly skin checks were not performed or documented as required. For another resident with diagnoses such as osteomyelitis, hepatitis B, and septic pulmonary embolism, the care plan included weekly skin checks due to impaired or at-risk skin integrity. Despite this, the medical record showed only one skin evaluation, and there was no evidence of a weekly skin assessment schedule or documentation of skin checks for this resident. Staff interviews revealed that the unit did not have a weekly skin assessment schedule in place, and the DON acknowledged the missing assessment, stating that a provider's note was being counted as a skin assessment, although this did not meet the facility's policy requirements. The facility's policy required licensed nurses to complete and document weekly skin evaluations for all residents. Observations, interviews, and record reviews demonstrated that this policy was not consistently followed, resulting in a failure to provide care and treatment according to physician orders, resident care plans, and professional standards of practice for the two residents involved.