Failure to Consistently Document Weekly Skin Locations and Measurements
Penalty
Summary
The deficiency involves the facility’s failure to document weekly skin locations and measurements for a resident with identified skin impairments, as required by the care plan and facility policy. The resident had no cognitive impairment, could communicate effectively, and had diagnoses including hypertension, diabetes mellitus, pneumonia, and a non-pressure skin ulcer. The care plan for actual/potential skin impairment, initiated on 10/15/25, directed staff to monitor and document the location, size, and treatment of skin injuries and to complete weekly treatment documentation including measurements (length, width, depth, tissue type, exudate, and notable changes). Multiple Skin Observation Tools documented skin tears and abrasions on the resident’s toes, right foot, and other areas, but repeatedly lacked required measurements and specific locations. For example, a 1/25/26 entry noted skin tears on the left and right toes without measurements, and subsequent entries on 1/28/26, 2/4/26, and 2/11/26 described bruising, scratches, abrasions, and skin tears but did not include measurements or precise locations. The resident was observed on more than one occasion lying in bed with the bottoms of both feet resting against the bed’s footboard, and the resident reported that resting his feet against the footboard caused sores on the bottom of his right foot and toes. A later Skin Observation Tool on 2/25/26 documented a right toe skin tear with measurements and noted scabs on the bottom and side of the right 5th digit, and a 3/2/26 Skin Issues Note recorded a right lateral foot skin tear with specific dimensions, acquired in-house with an unknown onset. Despite these later measurements, the DON acknowledged that the clinical record lacked documentation of the locations and sizes of the areas on the bottom of the resident’s right foot, and stated that nursing staff were expected to follow the facility’s Weekly Skin Assessment and Documentation Process policy, which required weekly documentation and separate assessments for each skin/wound alteration. This failure to consistently document weekly skin locations and measurements for the resident’s skin impairments constituted the cited deficiency.
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