F0686

D

Failure to Complete and Document Ordered Weekly Skin Assessments for High-Risk Residents

Plymouth, Minnesota Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to perform and document comprehensive weekly head-to-toe skin assessments as ordered for three residents with existing pressure ulcers and high risk for skin breakdown. For one resident with cancer, deep vein thrombosis, malnutrition, bowel and bladder incontinence, chemotherapy treatment, and mobility limitations requiring a wheelchair, provider orders dated 12/5/25 required weekly head-to-to-toe skin checks on Fridays. This resident had pressure wounds on both ischial tuberosities and later a sacral wound, and the care plan identified multiple risk factors for skin alteration, including a non-healing surgical wound, immobility, nutritional risk, and incontinence. Despite these orders and risk factors, the electronic health record showed only one weekly skin assessment on 12/26/25, with no documented weekly assessments for multiple weeks and no documentation that assessments were completed or refused.

A second resident, with intact cognition, peripheral vascular disease, kidney disease, neurogenic bladder, paraplegia, diabetes, and wheelchair dependence, also had provider orders for weekly head-to-toe skin checks on Fridays. This resident had a stage IV sacral pressure ulcer and ongoing pressure wound care orders, indicating high risk for pressure injury. Skin assessments were documented on 1/2/26, 1/9/26, 1/23/26, and 2/6/26, but there was no documentation of weekly skin assessments for the weeks of 1/16/26 and 1/30/26. The progress notes did not show that the missing assessments were completed or that the resident refused them.

A third resident, with intact cognition, current pressure ulcers, bowel and bladder incontinence, peripheral vascular disease, diabetes, lung disease, and wheelchair dependence, had provider orders for weekly head-to-toe skin checks on Sundays and ongoing pressure wound care orders for bilateral ischial tuberosity wounds. The care plan identified potential skin alteration and a non-healing open area related to diabetes, PVD, immobility, nutrition risk, incontinence, and impaired cognition. Documented weekly skin assessments occurred on 1/11/26, 1/25/26, 2/1/26, and 2/8/26, but there was no weekly skin assessment documented for the week of 1/18/26, nor any indication in the progress notes that the assessment was completed or refused. Nursing staff, including an LPN, two RNs, and the DON, acknowledged that weekly skin assessments were required by provider orders and facility policy, that admission body audits and wound rounds did not replace weekly head-to-to-toe assessments, and that these residents missed required weekly skin assessments without documented reasons.