F0676

D

Failure to Provide Ordered Weekly Skin Assessments and Scheduled Showers for One Resident

Camp Verde, Arizona Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide activities of daily living (ADL) care, including bathing and required skin assessments, to one resident in accordance with physician orders, the care plan, and facility policy. The resident was admitted with diagnoses including a right femur fracture, type 2 diabetes mellitus with hyperglycemia, muscle weakness, and right knee osteoarthritis, and had a BIMS score of 8 indicating moderately impaired cognition. On admission, the resident had a red coccyx, a thigh rash, and a scab on the right knee, and an order dated January 16, 2026, required a complete weekly skin check. The care plan identified the resident as at risk for functional self-care deficits and skin impairment, with interventions including skin inspection during routine care and per bath schedule, and monitoring for redness, open areas, scratches, cuts, bruises, and reporting changes to the nurse.

Record review showed that only one skin assessment was documented on January 16, 2026, with no evidence of any weekly skin assessments from January 17 through February 11, 2026, despite the standing order. A Braden scale assessment on January 30, 2026, documented that the resident’s skin was occasionally moist, and a Braden scale on February 9, 2026, documented skin occasionally moist, activity chairfast, and mobility slightly limited, but there was no documentation of follow-up weekly skin assessments or of the previously noted coccyx redness after January 16. The interim DON confirmed that there was only one documented weekly skin assessment despite the order, and the LPN stated she was not aware until February 16 that LPNs were responsible for weekly skin assessments. Both the LPN and DON acknowledged that weekly skin assessments were expected and that the previous DON had followed up with nurses on resident skin assessments.

The facility’s shower schedule indicated the resident was to receive showers twice weekly on the evening shift, and the CNA reported the resident was scheduled for showers every Tuesday and Friday, with an option for Sunday if preferred. However, shower documentation showed only two showers provided, on January 30 and February 7, 2026, with no evidence of showers from January 16 through January 29, from February 1 through February 6, and from February 8 through February 11, 2026. The CNA stated she did not provide any showers to this resident and that during showers, staff were expected to assess skin and document any skin conditions or refusals on shower sheets, which nurses would review and sign. The LPN reported she could not locate the resident’s shower sheets in the binder. Facility policies on Personal Care: ADLs and Bathing and Showers required that appropriate hygiene care be provided per the plan of care and that showers be used as an opportunity to observe and document the condition of the resident’s skin, but the documented care for this resident did not meet these requirements.