Failure to Complete and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to complete and document weekly skin assessments as ordered for one resident with diagnoses including Alzheimer's disease, diabetes mellitus type II, and major depressive disorder. The resident, who had severe cognitive impairment, was wheelchair-bound, and dependent on staff for all activities of daily living, had a physician's order for weekly skin assessments every Friday. Review of the clinical record showed that after an assessment on 8/22/25, no further weekly skin assessments were documented for 8/29/25, 9/5/25, and 9/12/25. During interview, the Corporate Nurse Consultant confirmed that all ordered skin assessments should have been completed and documented as scheduled. Facility policy required weekly skin assessments by a licensed nurse, but these were not performed or recorded for the specified dates.