Failure to Accurately Document Skin Assessments and Medication Administration
Penalty
Summary
The facility failed to ensure accurate and timely documentation of skin assessments for one resident. During an observation of incontinence care, the resident was noted to have a large purple discoloration on both buttocks, and barrier cream was applied. The resident’s diagnoses included diabetes mellitus, hemiplegia, and a left below-knee amputation, and the MDS indicated the resident was cognitively intact and dependent on staff for several ADLs. Physician orders and the skin integrity care plan required weekly skin assessments, documentation of skin condition, and notification of the MD for abnormal findings. A hospital after-visit assessment documented a non-blanchable purple discoloration on the buttocks, but subsequent admission and weekly skin observations, including the most recent one, documented no skin discolorations. The RN and Wound Nurse later indicated the resident had purple discoloration on the buttocks since admission, but staff had not documented its presence. The facility also failed to ensure accurate documentation of medication administration for another resident receiving calcitonin-salmon nasal spray. The resident had chronic obstructive pulmonary disease and required setup assistance for eating. Physician orders directed calcitonin-salmon spray to be administered to alternating nostrils on different days. A pharmacy consult noted staff were not giving calcitonin spray as ordered and recommended staff education on proper administration. Review of the eMAR showed that staff documented administering the spray to the left nostril on some days when the order was for the right nostril, and to the right nostril on some days when the order was for the left nostril. The DON stated that staff were administering the calcitonin spray as ordered but were not documenting it correctly. The facility’s documentation policy required accurate, organized documentation of all resident information, including weekly skin and vital sign assessments and wound management entries.
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