Failure to Accurately Document Resident Skin Assessments
Penalty
Summary
The facility failed to ensure that skin assessments accurately reflected the resident's current condition for one resident reviewed. Specifically, the skin assessments completed on two separate dates did not document the presence of a bruise on the resident's knee or a bruise on the resident's cheek, despite these being observable during care and reported by staff and the resident's representative. The resident's care plan required regular skin inspections and documentation of any redness, open areas, scratches, cuts, or bruises, but these requirements were not met in this instance. Interviews with staff revealed that both CNAs and nurses were responsible for checking and reporting skin issues during routine care, such as bathing or dressing. However, the staff involved either did not notice the bruises or failed to document them in the resident's medical record. The treatment nurse and DON confirmed that weekly skin assessments were required and that any findings should be documented and reported, but there was a lack of clarity among staff regarding monitoring and reporting procedures. The skin assessment policy required a thorough head-to-toe examination and documentation of any skin conditions, including bruising, which was not followed in this case. The resident involved had multiple diagnoses, including Alzheimer's disease, heart failure, COPD, diabetes, major depressive disorder, hypertension, delusional disorder, and dementia, and was at risk for falls as noted in the care plan. The failure to document observed bruises meant that the resident's medical record did not accurately reflect his condition, and the facility did not follow its own policy and care plan requirements for skin assessment and documentation.