Failure to Complete Timely Skin Assessments and Wound Care for Residents with Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and complete skin assessments and wound care for residents with pressure injury risk or existing wounds. One resident with Alzheimer’s disease, diabetes, atherosclerotic heart disease, hypertension, impaired cognition, and significant dependence for mobility and toileting was care planned for weekly skin checks and had a Braden score indicating risk for pressure ulcers. After the admission assessment, no skin assessments were documented for this resident until nearly two months later, when a right heel pressure area was identified. The initial skin assessment documenting this right heel pressure area did not include measurements, and although the resident was added to the wound round list with a documented unstageable DTI and specified treatment, the corresponding physician treatment orders for the right heel were not entered and initiated until eight days after the wound was first documented. The DON confirmed that weekly skin assessments were not completed as care planned and that the wound treatment orders were delayed. Another resident with diabetes mellitus type 2, gout, CHF, and depression, who was dependent for bed mobility and transfers, was readmitted with a documented stage 2 pressure injury and a DTI present on admission. The readmission skin assessment noted a left heel blister but did not include any wound measurements. A physician order was in place for daily wound care to the left heel, and the treatment was documented as completed on the TAR. However, wound rounding documentation showed a visit had to be rescheduled, and no measurements of the large left heel blister were taken from readmission through the date when the blister began to pop and seep fluid and the resident complained of pain and requested transfer to the hospital. The DON verified that no measurements were obtained for this left heel blister during that period. Facility policy required routine skin observation and implementation of preventive care plans, which was not followed in these cases.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.