Failure to Complete Ordered and Policy-Required Skin Assessments Leading to Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to provide timely skin assessments and implement preventative measures to prevent the development of a pressure ulcer for one resident, resulting in a facility-acquired Stage 3 pressure ulcer to the coccyx. The resident, who had multiple diagnoses including atrial fibrillation, seizure disorder, CVA, obesity, dementia, and severe cognitive impairment (BIMS 3/15), was totally dependent on staff for self-care and mobility, including turning, repositioning, and transfers. On admission, the resident’s skin was documented as intact, and the physician ordered weekly skin assessments on shower or bath day. However, from admission on 10/3/25 until 10/31/25, there were no documented weekly skin assessments. A Stage 2 pressure ulcer to the coccyx was first documented on 10/31/25, and by 11/11/25, the wound care physician documented a Stage 3 pressure ulcer to the sacrum measuring 4 x 5.5 x 0.1 cm. Interviews with the wound care nurse, DON, and Director of Clinical Services revealed that CNAs were expected to complete shower and skin alteration sheets and report changes to the nurse, and nurses were expected to complete weekly skin assessments and follow the physician’s orders. The facility, however, did not retain shower sheets or skin impairment sheets beyond one month, and no routine weekly skin assessments were found in the electronic medical record or MAR as required by the physician’s order and facility policy. The facility’s Pressure Injury and Skin Condition Assessment Policy required weekly skin assessments x4 for residents at high risk per Braden scale, daily observation for skin breakdown during care and on bath day, and documentation of weekly head-to-toe assessments by a licensed nurse. In the absence of documentation, the facility could not demonstrate that required skin assessments were completed or that the pressure ulcer was unavoidable in accordance with professional standards of practice and facility policy.
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