F0658

D

Failure to Complete and Document Ordered Weekly Skin Assessments

Jonesburg, Missouri Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

Facility staff failed to meet professional standards of practice by not completing ordered weekly skin assessments for one resident. Facility policies on Skin Integrity and Skin Observation required that the medical record contain all documentation regarding skin assessments and that a full head-to-toe skin observation be conducted by an RN or LPN upon admission/re-admission and weekly thereafter. The resident’s care plan identified impaired cognition and risk for skin breakdown and pressure ulcers, and the Quarterly MDS documented moderate cognitive impairment. Physician’s orders directed weekly skin assessments on specific days and shifts. Review of the resident’s December weekly skin assessment documentation showed no recorded assessments on 12/05/25, 12/12/25, and 12/19/25, and the MDS nurse confirmed that no weekly skin assessments were documented from 11/28/25 through 12/21/25 despite existing orders.

Nursing documentation showed that on 12/21/25 a deep tissue injury (DTI) was identified on the resident’s sacrum, and the resident also had a pressure ulcer on the left heel, both described by RN A as facility-acquired and expected to be documented on the weekly skin assessments. Additional physician’s orders on 01/02/26 included topical treatments to the buttocks and left heel. Interviews with the MDS nurse, RN A, the DON, and the Administrator confirmed that the charge nurse was responsible for completing and documenting weekly skin assessments, that the electronic system would have prompted these assessments, and that all physician’s orders were expected to be followed. The DON and Administrator stated they were not aware that the weekly skin assessments had not been documented during the identified period and acknowledged that if it is not documented, it is considered not completed.