F0686

E

Failure to Complete Required Braden and Weekly Skin Assessments for At-Risk Residents

Longview, Texas Survey Completed on 02-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure ulcer prevention and monitoring consistent with its own policies and professional standards for two residents at risk for pressure injuries. For one resident with heart failure, muscle weakness, diabetes, severe cognitive impairment, and identified risk for pressure ulcers, the care plan noted risk factors including fragile skin, incontinence, impaired mobility, and nutritional and hydration risk, with an intervention to identify and document potential causative factors. A Braden Scale assessment documented a score of 21, indicating no risk, but no further Braden assessments were documented for this resident from early June of one year through late February of the following year. A weekly skin check documented no skin issues in late January, and there were no further weekly skin assessments documented from that date through the resident’s discharge to the hospital in late February, despite facility policy requiring weekly full-body skin assessments and quarterly Braden assessments.

For this same resident, a wound care NP completed an "At Risk Skin Assessment" in early February, documenting no new skin abnormalities and no active wounds, while noting the resident remained at increased risk due to age, history of falls, and reduced mobility, and recommending continued skin surveillance at routine intervals. Later in February, a change of condition note by an LVN documented a small wound on the buttock, and a subsequent progress note the same day recorded that the resident had a small wound to the buttock and black, tarry stool, after which EMS was called and the resident was sent to the hospital. A hospital wound care nurse note the next day documented that on admission the resident had a Braden score of 14 (moderate risk), required maximum assistance for turning and repositioning, was incontinent of stool, and was saturated in urine with a dry Foley bag. The hospital note identified a POA stage 2 pressure injury to the left buttock with specific measurements and characteristics, macerated tissue to the bilateral buttocks concerning for a moisture component, and pale pink intact scar tissue on the right buttock.

The second resident was an older adult with diabetes, dementia, and protein-calorie malnutrition, with severe cognitive impairment and identified risk for developing pressure ulcers. The care plan documented diabetes and bowel incontinence related to cognitive decline. A Braden Scale assessment showed a score of 16, indicating risk for pressure injury, but there were no further Braden assessments documented for this resident for more than two years, despite the facility’s policy requiring quarterly Braden assessments and weekly skin assessments. A wound evaluation by a wound care NP in late February documented a diabetic wound on the right first toe but did not identify any pressure injuries, and a skin check shortly thereafter did not indicate any new skin issues. During interviews, the DON confirmed that Braden assessments were expected quarterly and skin assessments weekly, acknowledged that the last Braden and skin assessments for the first resident and the last Braden for the second resident were significantly outdated, and stated that failure to complete these assessments could result in unrecognized skin problems and lack of appropriate interventions. The Administrator and DON both attributed the missing assessments to a perceived glitch in the electronic charting system that was not triggering the required Braden and skin assessments.