Failure to Prevent and Manage Pressure Injuries and Monitor Skin Integrity
Penalty
Summary
Surveyors identified that the facility failed to provide necessary treatment and services to prevent and treat pressure injuries for three residents. One resident was admitted with moisture-associated skin damage (MASD) and later developed open areas on the buttocks, which were not reassessed as stage 2 pressure injuries in a timely manner. Weekly skin assessments were not completed as required, and the care plan was not revised after the development of new open areas. The resident was also observed sitting in a recliner without a pressure-relieving cushion, despite reporting discomfort and using a bed pillow for relief. Another resident developed a pressure injury on the coccyx, but comprehensive assessments were not completed when the injury was first identified. There were multiple nursing notes documenting an open area on the coccyx, but no detailed assessment or treatment was initiated until over a month later. The care plan was not updated promptly, and the resident was repeatedly observed sitting in a personal recliner without a pressure-relieving cushion, contrary to care plan interventions for pressure relief. A third resident wore a wanderguard directly on the skin without a sock underneath, and there was no documentation of daily skin checks under the device, despite the risk for skin breakdown. The care plan and physician orders did not initially include interventions to monitor skin integrity under the wanderguard, and nursing staff confirmed that skin checks were not being performed. The deficiency was only addressed after surveyor intervention, with no evidence of prior monitoring or documentation.