Missed Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to complete weekly skin assessments for a resident identified as being at risk for pressure injuries, as required by the resident's care plan and the facility's own policy. Specifically, the weekly skin assessments were not documented for two out of ten weeks. The care plan, which was last reviewed and updated, included an intervention for weekly skin assessments due to the resident's risk factors such as incontinence. However, there was no active order for weekly skin assessments in the resident's medical record, and the electronic medical record did not reflect completed assessments for the specified weeks. The resident in question was a cognitively intact male with diagnoses including encephalopathy, acute cholecystitis, and sepsis. He required partial to moderate assistance with mobility and was at risk for developing pressure injuries, though he did not have any present at the time. Documentation review showed that during the weeks in question, there were no progress notes describing the resident's skin status, and the assigned LPN could not recall completing the required assessment. The DON confirmed that unless an order was entered, the weekly skin assessment would not appear on the Medication or Treatment Administration Record, which contributed to the missed assessments. Interviews with staff indicated that while the resident received frequent care such as incontinence brief changes and shower assistance, which could have allowed for informal skin monitoring, the formal weekly skin assessments required by policy and care plan were not completed or documented. The facility's policy clearly outlined the need for weekly full-body skin assessments by a licensed or registered nurse, with specific documentation requirements, which were not met in this case.