Failure to Complete Weekly Skin Assessments for Resident with MASD
Penalty
Summary
The facility failed to follow its policy and procedure regarding skin breakdown by not performing weekly skin progress reports for a resident with moisture-associated skin damage (MASD). The resident had multiple risk factors, including diabetes mellitus, generalized muscle weakness, immobility, incontinence, and a history of candidiasis, all of which increased the likelihood of skin breakdown and infection. Documentation showed that the resident was dependent for personal hygiene and had documented skin impairment, with a care plan in place to resolve skin damage and reduce infection risk through regular skin assessments and weekly body checks. Despite these interventions being outlined in the care plan and facility policies, licensed nurses did not complete the required weekly skin assessments or progress reports for the resident during the specified month. Interviews with the treatment nurse and DON confirmed that weekly assessments were not performed, and the facility's policies required such monitoring and documentation. The lack of weekly assessments meant that the resident's MASD was not regularly evaluated for changes or response to treatment, as required by facility policy.