Failure to Document and Assess Resident's Skin Condition Weekly
Penalty
Summary
Licensed nurses failed to accurately assess and document a resident's skin condition weekly, as required by facility policy and professional standards. The resident, who had a history of unspecified psychosis, mobility issues, and muscle wasting, was admitted with multiple open skin scratches caused by persistent itching. Physician orders were in place for topical treatment of the skin issues, but documentation of ongoing skin assessments was missing from the medical record for a period of over six weeks. Record review revealed that after an initial skin assessment on 8/29/2025, there were no further Licensed Nurse Skin Assessment Forms or other documented skin assessments from 8/30/2025 to 10/15/2025. During this time, the resident continued to experience widespread open skin scratches and excoriations, as observed by nursing staff and confirmed during interviews. Staff noted that the resident's skin condition remained unchanged, with numerous new and healed scratch marks visible on various parts of the body, but there was no documentation of these findings in the medical record. Interviews with nursing staff and the Director of Nursing confirmed that required weekly skin assessments were not completed or documented, and that changes in the resident's skin condition were not communicated to the physician as expected. Facility policies required timely and detailed documentation of skin assessments, including any changes or treatments, but these procedures were not followed for the resident during the identified period.