Failure to Consistently Prevent and Address Pressure Ulcers
Penalty
Summary
A deficiency occurred when the facility failed to consistently provide services to prevent pressure ulcers for a resident at risk due to decreased mobility, incontinence, and fragile skin. The resident reported developing a pressure ulcer, attributing it to insufficient staff assistance during incontinence episodes. The care plan included weekly skin checks and physician orders for weekly skin assessments with notification of any breakdown. However, documentation showed the most recent skin assessment was completed on 5/24/25, noting redness and excoriation in the groin, buttocks, and perineal area, with no evidence of new orders or progress notes addressing these issues. The DON confirmed that the required skin assessment for 5/31/25 was not completed, despite the treatment administration record being signed off, and that the expected intervention of ordering a barrier cream and further assessment was not carried out.