Incomplete Documentation of Skin Assessment Findings
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident who was reviewed for total body skin assessment documentation. Upon readmission, a nurse did not document the presence of a bandage on the resident's forearm/elbow area, and later, another nurse failed to provide detailed documentation of a skin irregularity, including measurements and descriptive details, when assessing the resident's right arm. Both nurses acknowledged during interviews that they did not document their observations, with one stating she did not think it warranted documentation at the time, and the other admitting she did not think to include details in her note. The resident involved was an older male with multiple diagnoses, including cerebral infarction, muscle wasting, intellectual disabilities, hemiplegia, and hemiparesis. He had intact cognition and required assistance with most activities of daily living. The care plan indicated an actual impairment to skin integrity on the right antecubital fossa related to a Coban wrap, with interventions to monitor and document the injury. However, the medical record review showed that the resident was not coded for a major skin irregularity or wound, and the skin observation tool only noted redness without further detail. Interviews with staff and review of facility protocols confirmed that the expectation was to document all observational findings with detail, including measurements, description, and other relevant characteristics. The Director of Nursing stated that the nurses should have documented their findings as part of standard practice to ensure resident safety and proper monitoring of skin conditions. The lack of documentation was acknowledged by the staff involved, but it was noted that there were no negative outcomes for the resident as a result of these omissions.