Failure to Perform Required Braden Scale Assessments for Pressure Injury Progression
Penalty
Summary
The facility failed to ensure that Braden scale risk assessments were performed as required for a resident with a pressure injury. According to the facility's policy, risk assessments should be conducted weekly for the first four weeks, upon significant changes in condition, or as often as needed based on the resident's status. Medical record review showed that a resident, who lacked capacity to make decisions, was readmitted and subsequently developed a Stage 1 pressure injury that progressed to Stage 2 and later to Stage 3. Documentation confirmed the progression of the wound, but there was no evidence that repeated Braden scale assessments were completed at the time of these changes. Interviews with facility staff, including an LVN and the DON, confirmed that Braden scale assessments were not performed when the resident's pressure injury advanced from Stage 1 to Stage 2 and then to Stage 3. The LVN stated that Braden assessments were only done upon admission and not when there was a change in the wound's condition. The DON verified that the required assessments were missed during the periods when the resident's skin condition changed.