Failure to Complete Weekly Skin Assessments for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards of practice to prevent pressure ulcers, as evidenced by the lack of weekly skin assessments for seven residents reviewed for skin assessments. These residents had multiple risk factors for skin breakdown, including impaired mobility, incontinence, diabetes, dementia, and other chronic conditions. Despite care plans indicating the need for regular skin assessments and interventions to prevent pressure injuries, electronic medical records showed that weekly skin assessments were not completed for several consecutive weeks for these residents. Observations and interviews revealed that the facility's new electronic medical record (EMR) system did not consistently generate reminders or assignments for weekly skin assessments if the previous assessment was not completed. Nursing staff, including LVNs and RNs, reported relying on the EMR to prompt them for required assessments, and some were unaware that missed assessments would prevent future reminders. The Director of Nursing (DON) confirmed that the issue with the EMR had led to missed weekly skin assessments and that staff were responsible for completing these assessments unless the resident was under the care of the wound care nurse and physician. Record reviews and direct observations of the affected residents indicated that, at the time of survey, no new pressure ulcers were identified, but some residents had other skin issues such as bruising, healed wounds, or areas of redness. The facility's policy required weekly risk and skin assessments, but these were not consistently performed as documented in the residents' records. Staff interviews further confirmed that the lack of completed assessments could result in residents not receiving necessary care.