Failure to Document Skin Assessment Findings
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to accurately document observed skin irregularities on a resident during an assessment. On the evening in question, both the LVN and a certified nursing assistant (CNA) observed discoloration and bruising on the resident's forearms while providing enteral nutrition. The CNA described a yellowish-brown bruise-like discoloration on the right forearm and the LVN noted a light brownish/light purple bruise on the right forearm and two small dots on the left forearm. Although the LVN reported the findings to the Director of Nursing (DON), she did not document the observations in the resident's clinical record as required by facility protocol and accepted professional standards. Record reviews showed that the resident's weekly skin assessments and progress notes did not reflect the skin irregularities observed on the specified date. The resident had a history of severe protein calorie malnutrition, dementia, and surgical aftercare, and was care planned for potential pressure ulcer development with instructions for staff to document any new skin issues. The lack of documentation meant that the resident's clinical record was incomplete and not accurately maintained, which is a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.