Failure to Complete and Document Braden Scale Assessments and Weekly Skin Checks
Penalty
Summary
The facility failed to ensure that Braden scale assessments and weekly skin checks were documented and completed according to facility policy for two residents reviewed for pressure injuries. For one resident with peripheral vascular disease and dementia, the clinical record did not show that Braden scale assessments were completed weekly during the first month of admission, missing two out of four required assessments. Additionally, the care plan required weekly skin checks, but documentation was incomplete. For another resident with a history of stroke, diabetes, and gastrostomy, the care plan required Braden scale assessments on admission and per protocol, as well as weekly skin checks. The medical record lacked documentation of a skin check for one week and missed a Braden scale assessment for another week during the first month. Further, several weeks lacked documentation of weekly skin checks, and wound evaluations did not consistently indicate that a full body skin check was performed. Facility policy and interviews confirmed that these assessments and documentation were required but not completed as specified.