Failure to Document Sacral Skin Tear and Complete Weekly Skin Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident by omitting documented skin issues from transfer documentation and not completing required weekly skin assessments. The resident was admitted with diagnoses including muscle weakness and cellulitis of the left lower limb and had an H&P indicating lack of capacity to understand and make decisions, while an MDS assessment indicated the resident could understand and be understood and required varying levels of assistance with ADLs. On 12/26/2025, an SBAR form documented a sacral skin tear measuring 3 cm by 0.5 cm by 0.5 cm. However, when the resident was transferred to a general acute care hospital on 1/4/2026 for fever, the Transfer Sheet completed at 5:02 p.m. did not include the resident’s sacral skin tear or skin condition, contrary to the facility’s discharge policy requiring assessment and documentation of the resident’s condition at discharge, including skin assessment. The facility also failed to complete the weekly skin assessment for the sacral skin tear that was due during the week of 12/28/2025 to 1/3/2026. Review with the DON showed there was no weekly skin assessment documented for the sacral skin tear identified on 12/26/2025, and the DON stated this was because there was no wound care provider available that week. This omission was inconsistent with the facility’s policy on prevention of pressure injuries, which required a comprehensive skin assessment with each weekly risk assessment and upon changes in condition according to the resident’s risk factors.
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