Failure to Complete and Document Weekly Skin Assessments per Policy
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices by not completing and documenting weekly skin assessments as required by facility policy and physician orders. The resident was an elderly female with epilepsy, dysphagia following a nontraumatic intracerebral hemorrhage, age-related physical debility, and a cognitive communication deficit, with a BIMS score indicating moderate cognitive impairment. Her care plan identified her as having actual or at risk for skin impairment related to incontinence and dependence on staff for toileting and mobility, and included an intervention to follow the facility’s practice for assessing skin and following the skin protocol. Her MDS indicated no current pressure ulcers, venous or arterial ulcers, or other wounds, and a prior skin and wound evaluation documented a healed surgical incision. The resident had an order for weekly skin checks that was discontinued on 09/11/25 and not reordered until 02/24/26, leaving a gap during which no weekly skin assessment orders were in place. Record review showed that her last documented skin and wound evaluation form was completed on 09/30/25, and the DON confirmed that staff had not been doing skin assessments on this resident since sometime in September 2025. The facility’s Skin and Wound Prevention and Management policy required a licensed nurse to conduct and document a routine weekly skin assessment to identify new pressure injuries or other skin concerns, but this was not done for the resident during the identified period. The DON acknowledged that it was not identified that the resident lacked skin assessment orders and that the RN supervisor and DON were responsible for ensuring orders and documentation were in place, and stated that this failure could negatively impact residents by leaving issues untreated in a timely manner.
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