Failure to Complete Required Admission, Skin, and Accident Assessments
Penalty
Summary
The facility failed to complete required admission, skin, and accident assessments as ordered and per policy for several residents. For one resident admitted after digestive surgery with multiple comorbidities, there was no documented admission assessment or assessment of the surgical wound upon arrival. Although the wound nurse and primary nurse attempted to assess the surgical site, the assessment was not completed due to the resident's transfer to the hospital, and only vital signs were documented. The resident and family had expressed concerns about care, but no further information was provided. Another resident with a history of femur fracture, stroke, and other significant diagnoses experienced a burn incident involving hot tea. The initial assessment failed to document the presence of reddened skin on the right arm and back immediately after the incident. Blistering was only documented in a subsequent assessment, and the President of Clinical Operations confirmed that the initial assessment should have included the redness observed prior to blistering. For two additional residents with pressure ulcers, the facility did not complete or document weekly skin evaluations as ordered by the physician. In both cases, the electronic medical record lacked required skin evaluations for multiple weeks, despite physician orders and care plans indicating the need for regular skin checks. The Treatment Administration Record also showed missed documentation of these evaluations. The President of Clinical Operations acknowledged the missing documentation and indicated an understanding of the concern.