Failure to Identify and Assess Pressure Injuries in High-Risk Resident
Penalty
Summary
The facility failed to identify and properly assess pressure injuries in a resident who was admitted with severe cognitive impairment, was dependent on staff for all care, and was at high risk for pressure injuries due to conditions such as severe protein-calorie malnutrition, anemia, Alzheimer's Disease, and incontinence. Upon admission, the resident had no open wounds, but was always incontinent and required frequent repositioning and assistance with mobility. Despite these risk factors, the facility did not document any open wounds at admission. On 6/4/25, nursing progress notes indicated the presence of two small superficial open areas on the resident's buttocks, but there was no documentation of measurements, staging, or a thorough assessment of these wounds. Later, on 6/24/25, a new stage 2 pressure injury was identified on the resident's right shoulder, with measurements recorded. Interviews with staff confirmed that skin checks should have been performed regularly and that wounds should have been identified and documented before advancing to stage 2. The facility's own policy required detailed documentation of wound type, stage, location, size, and other characteristics, which was not followed in this case.