Failure to Routinely Assess and Document Wound Status
Penalty
Summary
Facility staff failed to provide the highest practicable care regarding wound assessment for a resident with dementia and high risk for skin breakdown. The resident was identified as having a Braden Score of 12, indicating high risk for pressure ulcers, and was noted to be incontinent of bowel and bladder. Initial documentation on June 6, 2025, identified the development of moisture-associated skin damage (MASD) on the sacrum, with measurements recorded and a fax sent to the medical provider. The care plan included the use of a moisture barrier and noted the resident's risk for altered skin integrity. Despite the initial assessment, subsequent clinical documentation repeatedly indicated that the skin issue had not been evaluated, and staff continued to document the wound as new over several months. There was no evidence that the MASD was routinely or comprehensively reassessed after the initial evaluation to determine if the wound was improving or worsening. An interview with the Director of Nursing confirmed that no further evidence of ongoing assessment could be provided.