Failure to Provide Consistent Pressure Ulcer Prevention Care
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A resident who was cognitively intact and required maximum staff assistance was admitted with a Stage 1 pressure ulcer. The resident's care plan specified that barrier cream should be applied to the buttocks three times daily to prevent further skin breakdown. However, clinical record review revealed multiple instances over a two-week period where there was no documented evidence that the barrier cream was applied as ordered during various shifts. Subsequently, the resident developed a Stage 2 pressure wound on the left buttock. The DON confirmed the lack of documentation for the application of barrier cream on the specified dates and times, which was required to prevent further skin breakdown.