Failure to Complete Required Skin Assessments and Braden Scales Resulting in Pressure Ulcer Development and Deterioration
Penalty
Summary
The facility failed to conduct and document required weekly skin assessments and Braden Scale evaluations for multiple residents, as outlined in their own policies. Several residents, including those admitted with existing wounds or at high risk for pressure ulcers (PU), did not receive comprehensive skin assessments upon admission or during their stay. For example, one resident admitted from a hospital with a history of endocarditis and multiple wounds did not have an admission skin assessment completed, and the presence, size, and characteristics of a coccyx wound were not documented. The facility also failed to initiate appropriate wound care orders or document physician notification for this resident, whose wound deteriorated to a Stage III PU and who was subsequently readmitted to the hospital. Other residents similarly did not receive weekly skin assessments or Braden Scale evaluations, despite being at risk for or developing pressure ulcers. One resident developed a Stage II PU that progressed to Stage III without any documented skin assessments or wound documentation. Another resident had wounds on the feet that were not documented or assessed, and a resident on hospice care developed open areas on the coccyx and buttock, as well as an unstageable PU on the heel, none of which were identified or documented by the facility. In these cases, there was also a lack of documentation regarding wound measurements, characteristics, and physician notification. Interviews with staff, including LPNs, CNAs, RNs, and the DON, confirmed that required skin assessments were not consistently performed or documented. Staff acknowledged that admission and weekly skin assessments should have been completed and that wounds should have been documented and reported to physicians for treatment orders. The facility's own policies required comprehensive skin assessments upon admission, weekly for four weeks, and with any significant change in condition, as well as the use of the Braden Scale to assess PU risk. These requirements were not met for several residents, resulting in a failure to provide appropriate pressure ulcer care and prevention.