F0686

D

Failure to Complete Admission Braden Assessment and Off-Loading Leading to Coccyx Pressure Injury

Albuquerque, New Mexico Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow professional standards of practice for pressure ulcer prevention for one resident identified as being at risk for skin breakdown. Record review showed that the facility’s Braden Scale policy required completion of a Braden assessment on resident move-in, but no Braden Scale assessment was completed on this resident’s admission date. Subsequent Braden assessments were documented only on 04/01/23, 04/08/23, and 04/14/23. The resident’s care plan, dated 04/28/23, identified the resident as being at risk for skin breakdown related to decreased activity, impaired cognition, limited mobility, poor safety awareness, incontinence, shear or friction, informed refusals of care, and recent right hip surgery noted on 03/28/23.

The care plan intervention for turning and repositioning every 1 to 2 hours was not added until 04/01/23, despite the identified risk factors. The report also notes a lack of documented off-loading of the coccyx area, which directly contributed to tissue necrosis and the development of a pressure injury to the coccyx. During an interview, the ADON confirmed that Braden Scale assessments are supposed to be done on admission and acknowledged that this did not occur for this resident.