Failure to Complete Required Braden Scale Assessments for Resident With Pressure Ulcer
Penalty
Summary
Surveyors identified a deficiency in pressure injury risk assessment when record review showed that a resident with a documented coccyx pressure ulcer on 03/06/26 had not received a Braden Scale assessment since 01/07/25. Review of the resident’s assessments confirmed the absence of any Braden Scale evaluations after that date, despite the presence of a pressure ulcer. In an interview on 03/12/26 at 4:39 PM, the MDS coordinator acknowledged that no Braden Scale had been completed since 01/07/25 and confirmed that such assessments were required quarterly or with any change in condition. Review of the facility’s Pressure Injury Prevention and Management Policy further showed that licensed nurses were required to conduct Braden Scale assessments on admission/readmission, weekly for four weeks, and then quarterly or whenever the resident’s condition changed, which had not been followed for this resident.
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