Failure to Identify and Assess Pressure Ulcer
Penalty
Summary
The facility failed to identify and comprehensively assess a pressure ulcer for one resident with multiple risk factors, including a recent femur fracture, type 2 diabetes, incontinence, and substantial assistance required for activities of daily living. The resident's care plan noted skin integrity impairment and interventions such as encouraging nutrition, hydration, and prompt treatment of skin breaks. Despite a Braden scale score indicating risk, a skin and wound evaluation did not identify an open area on the coccyx the day before the deficiency was observed. During care, nursing assistants discovered an open spot with fresh blood on the resident's coccyx, but the nurse was not called to assess the area at that time, as the resident was leaving for an appointment and declined further evaluation. The following day, an LPN was unaware of the wound until informed and then measured the area as 0.5 cm x 0.5 cm, confirming it was open. The LPN stated that wounds should be photographed, covered, and have a dressing order entered, with ongoing assessment on bath days and daily checks by nursing assistants. However, the wound had not been properly identified, assessed, or documented prior to this, and a nursing assistant reported that a nurse had previously been dismissive when informed of the wound. The facility's policy required prompt monitoring and addressing of skin integrity issues, but this was not followed in the resident's case.