Failure to Complete Required Skin and Elopement Assessments
Penalty
Summary
The facility failed to complete required assessments for two residents in accordance with its own policies. For one resident with dementia, Parkinson's disease, and osteoarthritis, weekly skin audits were not documented for two consecutive weeks, despite facility policy requiring weekly monitoring and documentation in the electronic health record. The resident was dependent on staff for mobility and had a low BIMS score, indicating significant cognitive impairment. The Director of Nursing confirmed that weekly body audits are required for all residents and could not provide documentation for the missed weeks. For another resident with dementia and a history of restlessness and agitation, quarterly elopement risk assessments were not completed as required. The resident was identified as high risk for wandering, but the clinical record did not show that Wandering Risk Scale evaluations were performed during two required quarters. This resident was later reported missing, with staff discovering an open window and screen in the resident's room. The DON acknowledged that quarterly assessments for elopement risk are required and could not explain the missed evaluations. Facility policy directs that all residents be assessed for wandering risk on admission and quarterly, with appropriate interventions if risk is identified.