Failure to Perform and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to provide services to prevent skin breakdown for three sampled residents by not performing weekly skin assessments as required by facility policy and care plans. The policy mandated head-to-toe skin inspections upon admission and weekly thereafter, with documentation in the electronic medical record. For one resident, there were no documented skin assessments for several specified weeks, despite the resident having a history of pressure ulcers and a care plan intervention for weekly skin checks. The resident's daughter also reported a lack of communication regarding the resident's status and wounds. Another resident, who was at risk for pressure injury and had active wounds being treated, also did not have weekly skin assessments documented for multiple weeks, including an entire month with no assessments. The care plan for this resident included weekly skin checks as an intervention to address the risk of skin breakdown. Similarly, a third resident with impaired mobility and vascular disease, and an order for weekly skin checks, had multiple weeks where no skin assessments were documented, despite staff signing off on the treatment administration record that the checks were completed. Interviews with nursing staff and the wound care nurse confirmed that the electronic system was designed to prompt nurses when skin assessments were due, and that documentation was to be completed in the electronic record. However, the lack of documented assessments for all three residents indicated that the required skin checks were not consistently performed or recorded, contrary to facility policy and physician orders.