Failure to Complete Required Weekly Skin Assessments for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent pressure ulcers for a resident at risk, as required by its own policy and procedures. The resident, who was admitted with diagnoses including muscle weakness, paraplegia, and end stage renal disease, was identified as having a deep tissue injury (DTI) on the sacrum upon admission. Physician orders and the care plan directed daily wound care and regular skin checks. However, review of the resident's records revealed that only the initial skin assessment was completed, and the required weekly skin assessments for the first four weeks after admission were not performed. During an interview and record review, the DON confirmed that weekly skin assessments should have been conducted and acknowledged that missing these assessments could allow the wound to worsen. The facility's policy specified that risk assessments should be repeated weekly for the first four weeks after admission, but documentation showed this was not followed for the resident in question.