Failure to Assess and Document CPAP-Related Nasal Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its own pressure injury and skin assessment policies for a cognitively intact resident who used a CPAP device and was assessed as being at moderate risk for pressure ulcers on multiple Braden Scale assessments. Facility policy required that pressure ulcers and other ulcers be assessed and measured at least every seven days by a licensed nurse, that each resident be observed daily for skin breakdown by CNAs with changes promptly reported to the charge nurse, and that the earliest sign of a pressure injury be documented in the clinical record and nursing progress notes with notification to the physician and resident or representative. The resident’s admission skin assessment and subsequent Braden Scale assessments did not document any pressure ulcer or skin alteration on the bridge of the nose, despite the resident’s use of a CPAP mask. Surveyor observation found the resident lying in bed with a CPAP device in place and, shortly thereafter, sitting on the edge of the bed with a bright red, dime-sized area on the bridge of the nose. The resident reported that this area had been present for over a week, was painful, and had been reported to staff about a week earlier, with the only response being application of a bandage. The resident stated the breakdown was caused by the CPAP mask due to the absence of a cushion and that the area hurt when touched or when the mask contacted it. The electronic medical record contained no documentation of the nasal area or the application of a bandage. The Assistant DON acknowledged seeing a bandage on the bridge of the resident’s nose previously but stated she was not aware that the resident had developed an ulcer there, confirming that the area had not been identified, assessed, or documented as a pressure injury in accordance with facility policy.
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