F0684

D

Failure to Complete Comprehensive Skin Assessment and Implement Ordered Pressure Injury Prevention

Walnut Creek, California Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a comprehensive skin assessment and pressure injury prevention for one of two sampled residents. The resident was admitted with diagnoses including congestive heart failure, atrial fibrillation, and a history of falls. An eINTERACT Change in Condition Evaluation documented a purple bump on the buttock, but the skin evaluation did not include the precise anatomical location or measurements (length, width, depth) of this newly identified skin abnormality, and there was no documentation that the cause or origin of the skin injury was investigated. A subsequent Wound Assessment Note, signed by the physician, identified the wound as an abrasion on the right buttock but again did not include wound measurements or specify the exact anatomical location on the buttock.

The same Wound Assessment Note indicated the resident had a pressure injury on the left heel and that the physician ordered a protective boot to offload pressure, but there was no documentation that this ordered device was implemented. During interviews, the Treatment Nurse stated that an investigation should have been conducted to determine the cause of the purple bump and that a complete assessment, including wound measurements and exact anatomical location, should have been performed. The DON stated that the purple bump should have been investigated to determine the cause and that without exact wound measurements it would be difficult to determine if the skin injury was improving or declining, and also acknowledged that the physician’s order for a preventive boot was not entered into the record or implemented. Review of the facility’s Wound Management policy showed that it required measurement of new wounds and documentation of wound location and measurements, which was not followed in this case.