Failure to Document Skin Assessments and Apply Treatments per Physician Orders
Penalty
Summary
Facility staff failed to consistently perform and document complete weekly skin assessments for multiple residents, as required by facility policy. For three residents, there was a lack of thorough documentation regarding skin conditions, including incomplete or missing weekly skin audits and insufficient descriptions of observed skin issues. In several instances, staff did not record whether there were new or existing skin problems, nor did they provide detailed assessments of rashes, edema, or open areas, despite ongoing or recurring skin concerns. This lack of documentation was observed over several weeks and across multiple residents with complex medical histories, including dementia, heart failure, and recent infections. Additionally, staff applied topical treatments, such as antifungal creams, to residents' skin conditions without obtaining physician orders. In at least two cases, nurse aides reported applying antifungal creams to rashes based on their own assessment, and these treatments were not documented in the physician's order sheets. The use of these medications without proper authorization was confirmed through interviews and direct observation of medication in residents' rooms. Furthermore, some skin conditions, such as persistent rashes and cellulitis, were not included in the residents' care plans, and care planning did not reflect the ongoing need for monitoring or treatment of these issues. The deficiencies were identified through a combination of record review, staff and resident interviews, and direct observation. Residents affected had significant medical histories, including cognitive impairment, recent or ongoing infections, and skin fragility. Despite physician involvement in some cases, communication gaps were evident, with physicians not being notified of changes in residents' skin conditions in a timely manner. The lack of comprehensive assessment, documentation, and adherence to physician orders contributed to the facility's failure to provide care according to professional standards and residents' needs.