Failure to Provide Consistent Pressure Ulcer Prevention and Assessment
Penalty
Summary
A resident with a history of right femur fracture, osteoarthritis, and non-ambulatory status was identified as being at risk for skin breakdown upon admission. The resident's care plan included interventions such as providing preventative skin care as ordered and conducting weekly skin checks by a licensed nurse. However, documentation revealed that staff failed to provide preventative skin care for 32 out of 36 opportunities in May, and weekly skin assessments were not completed after the initial assessment on 5/1/2025. Interviews with staff confirmed the lack of ongoing skin assessments and preventative care as outlined in the care plan. During interviews and direct observation, the resident reported having bed sores on the buttocks, and staff observed pink, blanchable areas on both buttock cheeks. The facility's wound nurse and Assistant Director of Nursing acknowledged that residents with impaired mobility and a history of pressure injuries require preventative skin care and regular assessments, but could not provide evidence that these interventions were consistently implemented for this resident. The failure to follow the care plan and professional standards of practice led to the deficiency in pressure ulcer prevention and care.