F0842

D

Inaccurate Weekly Skin Assessment and Documentation for Resident with Pressure Ulcers

Oklahoma City, Oklahoma Survey Completed on 02-18-2026

Penalty

Fine: $50,116

Summary

The facility failed to ensure accurate weekly skin assessments were documented for a resident with pressure-related skin issues, resulting in a discrepancy between nursing documentation and the resident’s actual skin condition. A physician’s order directed that the resident receive a weekly skin assessment every Thursday on night shift. The resident’s admission assessment documented diagnoses including an unspecified fracture of the sacrum and abnormalities of gait and mobility, and indicated intact cognition with a BIMS score of 15. During an incontinent care observation, the resident was seen with three open areas on the coccyx and buttocks. However, a weekly Skin Assessment by the charge nurse completed the previous night documented no open areas and only redness to the coccyx, while a subsequent skin assessment by the wound care nurse the next day identified stage 2 open areas on the coccyx and both buttocks. The LPN who completed the weekly skin assessment acknowledged that, contrary to facility policy requiring complete and accurate documentation and a head-to-toe assessment, they did not perform a complete skin assessment and, to their knowledge, did not visualize the coccyx and buttocks, and the DON stated nurses were to document only observed findings on the skin assessment.

The wound care nurse identified that there were 12 residents with wounds in the facility, and Resident #26 was one of three sampled residents reviewed for pressure ulcers and skin conditions in whom this documentation failure was identified.