Failure to Document Weekly Baths and Skin Assessments for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to accurately document weekly baths and complete current head-to-toe skin assessments for two residents, despite facility policy requiring a weekly bath or shower with a full skin assessment documented on a weekly skin assessment form. For one resident (R1), records showed admission in mid-December with a care plan identifying high risk for skin breakdown and interventions such as keeping fingernails short, using pressure-relieving devices, and preventing him from hitting his extremities. R1 required extensive assistance with hygiene and had a scheduled weekly bath. His TAR showed a dressing order for abrasions on multiple body areas to be treated three times weekly, yet only one weekly skin assessment form was found for his three-week stay, and that assessment documented a shower with no skin issues observed. The TAR for the following month showed weekly skin assessments acknowledged on two dates, but there was no associated documentation indicating the type of bath or any skin integrity findings. For another resident (R3), who required assistance from two staff for bathing, dressing, and toileting, and who had a Foley catheter, bowel incontinence, morbid obesity, a surgical wound, anxiety, PTSD, and Fournier disease affecting the vaginal and vulvar areas, documentation showed only two completed weekly skin assessments over a period of more than two months. Her TAR indicated scheduled baths on multiple dates, but there was no corresponding documentation of weekly skin assessments for each scheduled bath. Staff interviews confirmed that all residents were to receive a weekly bath or shower with a concurrent skin assessment documented on the weekly skin assessment form, and that the TAR only served as a reminder that a bath was due and did not capture whether the bath or skin assessment was actually completed. A nurse reported being able to locate only one weekly skin assessment for R1 during his entire stay, confirming the lack of required documentation for both residents.
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