F0842

E

Inaccurate Weekly Skin Audit Documentation for Residents With Known Wounds

West Saint Paul, Minnesota Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate and complete medical records, specifically weekly bath/skin audits, for multiple residents with known wounds. For one resident with dementia, bilateral above-knee amputations, vascular disease, and reduced mobility, the MDS indicated no ulcers or skin problems, yet wound documentation showed treatment for a stage 4 pressure ulcer on the right above-knee amputation site between 3/23/26 and 3/25/26. Despite this, the weekly bath audits on 3/17/26 and 3/24/26 either documented only non-tender lymph nodes on the right upper hip or indicated no new or old skin alterations, and did not reflect the existing stage 4 pressure ulcer.

Another resident with paraplegia and multiple documented pressure ulcers and wounds, including stage 3 and stage 4 pressure ulcers of the hips, heels, ankle, shin, calf, and medial malleolus, had numerous weekly bath audits over several weeks that consistently indicated no new or old skin alterations. This conflicted with wound documentation showing ongoing treatment for an open lesion on the right Achilles, stage 3 pressure ulcers on the right heel and right medial calf, an unstageable right medial malleolus wound, a left shin wound, and a stage 3 left heel pressure ulcer on multiple dates. Additional residents with diagnoses including malignant neoplasm of the prostate with stage 3 and stage 4 pressure ulcers, type 2 diabetes with skin ulcers and a stage 4 heel ulcer, and end-stage renal disease with peripheral vascular disease and documented pressure ulcers and an abscess, also had weekly bath audits that reported no new or old skin alterations while concurrent wound records showed ongoing treatment for heel ulcers, calf ulcers, toe pressure ulcers, and a coccyx abscess.

Interviews with nursing staff revealed inconsistent understanding and practices regarding documentation on weekly bath audits. Several RNs and LPNs stated that during baths or skin checks they look for redness, swelling, open wounds, and other skin issues, and that new findings should be documented on the weekly bath audit, with some indicating they would chart only if there was something new. One LPN stated she would chart “nothing new” if there were no new skin alterations. Another RN stated that any new or existing wound should be noted on the weekly bath audit, but also reported that prior to approximately three months earlier, staff had been instructed not to document existing wounds on these audits. A requested policy on weekly bath audits was not provided, and the lack of clear, consistent documentation practices led to weekly bath audits that did not accurately reflect residents’ known and treated wounds.