Failure to Document Newly Identified Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to document a newly identified skin condition in a resident’s clinical record in accordance with its Skin and Wound Management Guidelines. The guidelines required that all pressure-related injuries and moisture-associated skin damage be documented in the Skin and Wound Module, and that other alterations in skin integrity be described in detail in the resident’s progress notes. Resident #6 had a care plan identifying a potential for impaired skin integrity related to decreased mobility and bladder/bowel incontinence. During preparation for transfer of Resident #6 to the hospital for evaluation, an LPN identified a new reddened area on the resident’s buttocks but did not document this change in the resident’s clinical record. The Assistant Director of Nursing and the Director of Nursing both confirmed that the LPN should have documented the newly observed reddened area in the resident’s record. This failure to document the new skin alteration for Resident #6, despite existing facility guidelines and the resident’s identified risk for impaired skin integrity, led to the cited deficiency.
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