Missed Weekly Skin Assessment for Resident with Skin Injuries
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, a weekly skin assessment for a female resident with vascular dementia and moderate cognitive impairment was not completed as required. The resident had a history of being the recipient of aggression from another resident, resulting in skin injuries, and her care plan included interventions for monitoring and addressing skin integrity. Documentation showed that after an incident resulting in a bruise and skin tear, the last recorded weekly skin check was completed on 10/10/2025, with no subsequent weekly skin assessments documented as required. Interviews with facility staff revealed a lack of clarity regarding responsibility for completing the weekly skin assessments, with the assigned nurse unaware of the requirement and unable to provide a reason for the missed assessment. The ADON confirmed that the nurse should have completed the assessment, and the DON acknowledged the importance of timely skin assessments to monitor for changes or complications. The facility did not have a specific policy for weekly skin assessments, but staff agreed that such assessments should be performed and documented, or refusals noted. The absence of the required weekly skin assessment constituted a failure to follow the resident's care plan and professional standards.