Failure to Develop and Implement Weekly Skin Assessment Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans with measurable interventions and timetables for residents at risk for skin breakdown, as required by its own policy. Specifically, the care plans for several residents did not include interventions for routine weekly skin assessments, and for some residents, the existing care plan interventions for weekly skin inspections were not implemented. This deficiency was identified through observation, record review, and interviews, revealing that multiple residents with significant risk factors for pressure ulcers did not receive timely or documented weekly skin assessments. For example, one resident with end stage renal disease, diabetes, and a history of pressure ulcers had a care plan that lacked interventions for routine weekly skin assessments, and documentation showed missed weekly assessments over several months. Another resident with multiple Stage III and IV pressure ulcers and severe cognitive impairment also had a care plan without weekly skin assessment interventions, and only two assessments were documented over a two-month period. Additional residents with high or moderate risk for skin breakdown, as indicated by Braden Scale scores and other medical conditions, similarly lacked appropriate care plan interventions or did not receive weekly skin assessments as required. In several cases, new or worsening pressure ulcers were only identified during a facility-wide skin sweep, rather than through ongoing, routine monitoring. The surveyors determined that the facility's noncompliance with care planning and implementation requirements had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The deficiency was found to have existed for several months prior to the survey, affecting multiple residents with complex medical histories and significant risk factors for skin breakdown. The facility's own policy required person-centered care plans with measurable goals and regular updates, but these requirements were not met for the residents reviewed.