Failure to Monitor and Document Skin Alterations
Penalty
Summary
The facility failed to adequately monitor and document skin issues, specifically bruising, for a resident with known skin alterations. The resident, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease, dementia, and was receiving palliative care, was noted by a hospice shower aide to have bruising and swelling on her lower left extremity. Despite this observation, there was no documentation in the progress notes regarding the measurement, description, or exact location of the bruising. Subsequent progress notes and weekly skin assessments did not include any information about the bruising or other skin injuries, and shower logs also lacked documentation to support ongoing monitoring of the reported skin issue. Interviews with facility leadership, including the DON, Administrator, and ADON, confirmed that there was no documentation to show that the bruising was monitored, measured, or described after it was initially identified. Review of the facility's skin assessment policy indicated that a full body skin assessment should be conducted upon admission, daily for three days, and weekly thereafter, as well as after any newly identified skin injury. However, there was no evidence that these procedures were followed in this case, and hospice records also lacked descriptive information about the bruise.