Failure to Complete Weekly Skin Assessments per Policy
Penalty
Summary
The facility failed to ensure that a resident received weekly skin assessments as required by facility policy and the resident's care plan. The resident, who had diagnoses including cerebral infarction, atrial fibrillation, COPD, and hypertension, was identified as being at risk for skin breakdown due to factors such as thin, fragile skin, incontinence, and decreased safety during ambulation. Record review showed that while a skin assessment was completed at the beginning of the month, no weekly skin assessments were documented for four consecutive weeks in October. The care plan specifically noted the resident's risk for skin breakdown, and the facility's policy required weekly skin assessments to monitor for issues such as pressure injuries and wounds. Interviews with facility staff confirmed that weekly skin assessments were to be performed by a nurse, not by CNAs. The DON acknowledged that the missing assessments were not completed by a nurse and that the documentation provided for the missing weeks consisted only of shower sheets filled out by CNAs, which are not considered nursing assessments. The facility's policy, last revised in 2022, clearly stated that skin assessments must be documented at least every seven days by nursing staff.