Failure to Identify and Document New Pressure Ulcers in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to identify and document new skin alterations for a resident at risk for developing pressure wounds. The resident, a cognitively impaired male with a history of traumatic brain injury, bilateral lower leg amputation, lack of coordination, and unspecified dementia, was dependent on staff for most activities of daily living. During a skin check performed by the DON, two open areas were found on the resident's lower buttocks, both over previously healed pressure wounds. These areas were not listed on the facility's current list of residents with pressure wounds, and there was no documentation in the medical record of new skin assessments, orders, or progress notes related to these open areas. The resident had recently attended an appointment with a new primary care provider, during which two open areas were also identified by the provider's office nurse. However, the facility's records, including a shower sheet from the same day, only noted discoloration on the buttocks and did not document any open areas. The resident's care plan required daily and weekly skin checks, with instructions to notify the charge nurse of any new skin issues for further assessment and treatment. Despite these protocols, the new skin alterations were not promptly identified or communicated, resulting in a failure to provide appropriate pressure ulcer care and prevention.