Failure to Maintain Complete and Retainable Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and retrievable clinical records related to skin assessments and monitoring for one resident. A physician’s order dated 10/03/2025 required weekly skin assessments on the resident’s shower or bath day. The facility’s Pressure Injury and Skin Condition Assessment Policy dated 9/2016 required weekly head-to-toe skin assessments by a licensed nurse for residents at high risk, daily observation for skin breakdown by CNAs, and documentation of these assessments in the resident’s medical record or on facility-approved forms. During record review, only two skin assessments for the resident could be located in the medical record: one at admission on 10/03/2025 and one dated 10/31/2025 after skin breakdown was identified. The Wound Care Nurse (V4) reported that the facility used shower sheets and skin alteration sheets completed by CNAs to document skin observations, but stated that these records were not retained beyond one month per facility policy. The DON (V2) confirmed that the facility did not keep shower or skin assessment documentation beyond the current or previous month and that nurses were expected to complete and monitor skin assessments. The Director of Clinical Services (V3) stated that skin assessments were expected to be documented on the MAR, but review of the MAR showed no documented skin assessments as required by the physician order or facility policy. As a result, the facility could not produce documentation to verify that the ordered weekly skin assessments and required monitoring were performed for this resident.
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