Failure to Document Weekly Skin Assessments as Ordered
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically by not documenting physician-ordered weekly skin assessments over a period of approximately two months. The resident in question was an elderly female with multiple diagnoses, including dementia, psoriasis, and incontinence, and was identified as being at risk for skin breakdown. Her care plan and physician orders required weekly skin assessments by a licensed nurse, and the Treatment Administration Record (TAR) indicated that these assessments were signed off as completed. However, a review of the actual skin assessment documentation revealed that no detailed skin assessment records were completed for ten consecutive weeks. Interviews with facility staff, including the DON, LVN A, and the previous wound care nurse, confirmed that the required skin assessments were not documented as per facility policy, which mandates completion of a body diagram and detailed findings regardless of changes in skin integrity. The DON acknowledged the gap in documentation and stated that he had not previously noticed the missing assessments. LVN A, who was responsible for the assessments during the period in question, stated she had performed the assessments but did not document them and was unsure of the reason, suggesting she may have been hurried or lacked time. Both LVN A and the previous wound care nurse confirmed their understanding of the documentation requirements and the importance of completing the body diagram each week. The facility's policy on pressure ulcer and injury risk assessment requires that findings be documented on an approved skin assessment tool, including the type of assessment and the condition of the resident's skin. Despite staff training and annual competencies covering skin assessment documentation, the required records were not completed for the resident during the specified period. The lack of documentation was not identified or addressed by the wound care nurse or DON during routine monitoring, resulting in incomplete clinical records for the resident.