Failure to Perform Required Pressure Ulcer Assessments and Care Planning
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two of three sampled residents. For one resident with multiple comorbidities including diabetes, chronic kidney disease, dementia, and congestive heart failure, the facility did not perform weekly skin checks as ordered, nor did they complete weekly Braden Scale risk assessments after the initial admission assessment. The resident developed a reddened heel, a sacral pressure injury, and a deep tissue injury to the left big toe during their stay. Additionally, the dietician did not conduct a nutritional assessment after the development of pressure ulcers, despite facility policy and physician orders requiring such evaluations. For another resident with diabetes, chronic kidney disease, and intellectual disability, the facility also failed to perform weekly skin assessments as required, with missed documentation for two weeks. The Braden Scale risk assessment was not repeated after the initial assessment, and the dietician did not evaluate the resident's nutritional status following the identification of a pressure ulcer present on readmission. Furthermore, the resident's care plan and nurse aide care card were not updated to reflect necessary interventions for pressure ulcer prevention and care after the resident was readmitted with an unstageable pressure ulcer. Interviews with facility staff confirmed that weekly skin and wound assessments, Braden Scale evaluations, and timely nutritional assessments by the dietician were expected per facility policy but were not completed. The Director of Nursing and the dietician both acknowledged lapses in communication and adherence to protocols, resulting in the deficiencies identified. Review of facility policies confirmed the requirements for regular assessments and care plan updates, which were not followed for the affected residents.