Failure to Monitor and Assess Pressure Injuries and Skin Impairments
Penalty
Summary
The facility failed to routinely monitor and assess the status of skin impairments for two residents who were at risk for pressure injuries. One resident was admitted with a hip fracture, weakness, and impaired mobility, and was identified as having a stage 1 pressure injury over the sacrum. Although the care plan noted the risk for pressure-related skin injury, there were no documented measurements of the injury, no treatment or monitoring orders, and no follow-up documentation to indicate whether the injury was monitored, worsened, or improved after admission. Another resident, admitted with dementia, generalized muscle weakness, and incontinence, was identified as having moisture-associated skin damage and a small open area in the gluteal cleft. Initial documentation included measurements of the wound, but subsequent records lacked ongoing measurements or descriptions of the wound's status. There was no further documentation after the initial assessment to show that the open area was monitored or that its condition was tracked over time. The Director of Nursing Services confirmed that monitoring orders and weekly assessments should have been in place for both residents.