Failure to Complete and Document Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to complete physician-ordered weekly skin assessments or document resident refusals for two of four residents reviewed for quality of care. For one resident with diagnoses including rhabdomyolysis, type II diabetes, a history of coccyx fracture, and morbid obesity, the clinical record lacked documentation of weekly skin assessments on multiple specified dates, despite an active order for these assessments. The resident's care plan noted a history of refusing care, with interventions to monitor and document behavior and potential causes. A progress note later indicated a worsening wound with redness, warmth, odor, and necrotic tissue, leading to new medical orders for antibiotics and a specialty mattress. Another resident, diagnosed with COPD, diabetes, dementia, and toe contusions, also had missing documentation for weekly skin assessments as ordered. The care plan identified a risk for pressure ulcers due to decreased mobility and incontinence, with interventions including weekly head-to-toe skin assessments. The DON confirmed that assessments should be completed and documented as ordered, and refusals should be documented if they occur. Facility policy required weekly skin assessments and notification of the physician and IDT if residents refused treatment, but these procedures were not followed as required.