Failure to Complete Required Weekly Skin Assessments
Penalty
Summary
Facility staff failed to follow professional standards of care regarding skin assessments for one resident with significant risk factors, including traumatic wounds, paraplegia, and immobility. The resident's care plan required regular skin assessments to prevent further skin breakdown. Clinical records showed that weekly skin assessments were documented for several weeks, but there were no assessments recorded for three consecutive weeks. There was no documentation explaining the absence of these assessments or any indication that the resident refused them during this period. Interviews with the LPN unit manager and the DON confirmed that weekly skin assessments were required by facility policy and should have been prompted by the electronic health record system. Both staff members were unable to provide an explanation for the missing assessments, and no additional information was provided during the survey regarding the lapse. The facility's policy specified that skin assessments must be completed at least every seven days for all residents, but this was not followed in the case of the resident in question.