Failure to Complete Comprehensive Skin Assessments and Ensure Proper Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow its own policies regarding comprehensive skin assessments and pressure ulcer prevention for two residents with skin impairments. Upon readmission from the hospital, one resident with multiple diagnoses including diabetes, dementia, end stage renal disease, and a history of pressure ulcers did not receive a comprehensive skin assessment to identify the size and appearance of wounds or dressings present. Documentation was lacking for the presence and frequency of preventive interventions such as heel protectors, and there was no evidence that a low air loss mattress was used according to manufacturer recommendations. The wound nurse and LPN provided conflicting accounts regarding the condition of the resident’s legs upon readmission, with the wound nurse identifying open pressure ulcers and the LPN documenting only scars. No skin pictures were taken at the time of readmission, and the treatment administration record did not show any treatments for the resident’s legs on the day of readmission. Another resident, admitted with a stage 3 pressure ulcer to the sacrum and identified as high risk for skin breakdown, was observed on a low air loss mattress. However, the mattress was not set according to the resident’s actual weight, as required by manufacturer guidelines and facility policy. The resident’s weight was significantly lower than the mattress setting, and although staff stated that checks are performed to ensure correct settings, the observation revealed a discrepancy. The care plan for this resident included interventions for pressure ulcer prevention, but the implementation did not align with the operational manual for the mattress. Facility policies required comprehensive, person-centered care planning and specific interventions for residents at risk for skin breakdown. The lack of documentation, incomplete assessments, and failure to ensure proper use of pressure-relieving equipment contributed to the deficiencies identified by surveyors. These actions and inactions resulted in the facility not providing appropriate pressure ulcer care and not preventing new ulcers from developing, as required by their own policies and procedures.