Failure to Document Post-Abuse Allegation Skin Assessment
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident following an allegation of staff-to-resident abuse. After the allegation was reported, a registered nurse performed a skin assessment on the resident but did not document the assessment in the clinical record, as she stated she found no new findings. The resident had significant medical conditions, including congestive heart failure, altered mental status, aphasia, cerebral infarction, and cognitive communication deficit, with a recent assessment indicating severe cognitive impairment. Previous skin assessments noted bruising attributed to medication injections and blood draws, but no new documentation was made after the abuse allegation. Interviews with staff revealed that the nurse did not document the post-allegation skin assessment because she believed documentation was only necessary if new findings were present. The director of nursing stated that the expectation was for a head-to-toe skin assessment to be documented in the clinical record following any abuse allegation, either under the assessments tab or in a nursing progress note. The facility was unable to provide a specific policy regarding the accuracy of documentation in the clinical record, only a general policy on nursing care and services.