Failure to Assess and Monitor At-Risk Resident for Pressure Ulcers
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident at risk for pressure ulcers was properly assessed and monitored to prevent the development of pressure ulcers. The resident, who had a history of diabetes mellitus type II and hemiplegia following a cerebral infarction, was admitted without any skin concerns and was identified as being at increased risk for pressure ulcers based on a Braden score of 16. Despite this risk, there were no documented skin assessments for the resident between late January and early February. On February 10th, the resident was transferred to the hospital for altered mental status and slurred speech, with no documentation of skin concerns at the time of transfer. However, upon hospital admission, multiple unstageable pressure injuries and a deep tissue injury were identified on the resident's buttock and coccyx. The facility's own policy required regular assessment and monitoring of skin integrity, as well as prompt reporting of any changes, but these procedures were not followed for this resident. Interviews confirmed that there was no documentation of wounds prior to the resident's hospital admission, and the family was not informed of any skin issues by the facility. The hospital documented the pressure ulcers as present on admission, indicating that the facility failed to identify and report these injuries prior to the resident's transfer.