F0686

D

Failure to Perform Timely Nurse Skin Assessments and Wound Documentation for High-Risk Residents

Boone, North Carolina Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete timely and adequate skin and wound assessments, Braden Scale risk assessments, and prompt initiation of treatment for pressure ulcers for three residents. For one resident with hemiplegia, limited mobility, and hospice enrollment, the care plan identified risk for pressure ulcer development and called for weekly treatment documentation with measurements and detailed wound characteristics. However, there were no documented Braden Scale assessments in 2025 and no weekly skin assessments prior to mid-January 2026. Shower sheets from November documented a sacral pressure injury, but they were unsigned, and the ADON who recalled completing one sheet stated she assumed a dressing indicated the wound was already being treated and did not report it. Hospice notes from early November did not document a sacral ulcer, and there were no treatment orders or treatments for a sacral ulcer between the dates when the shower sheets noted a pressure injury and when the wound nurse documented a stage 3 sacral pressure ulcer with a new treatment order. The wound nurse later stated the ulcer was stage 3 when first identified and believed it might have been found earlier if routine nurse skin assessments had been completed.

A second resident with type 2 DM, neuropathy, peripheral angiopathy, and a history of diabetic foot ulcers had a care plan requiring daily inspection of feet and full-body checks for skin breaks. A Braden Scale was completed in early 2025, but no additional Braden assessments were documented until December 2025, and there were no weekly skin assessments documented before mid-January 2026. In November, weekly wound assessments documented a suspected deep tissue injury on the left plantar foot and an unstageable pressure ulcer with black eschar on the right plantar foot, with treatment orders initiated and later revised. The Wound PA and wound nurse attributed the plantar ulcers to the resident’s feet resting against the bed footboard and noted that the resident, due to neuropathy, could not feel his feet or the wounds. The unit manager reported that an NA initially found the wounds and notified her, and she then brought in the wound nurse. She also stated that, at the time the wounds were identified, nurses were not doing formal skin assessments and that NAs were performing skin checks during baths and completing shower sheets, with no consistent nurse-led weekly skin assessment schedule documented for this resident.

A third resident with hemiplegia, a history of a stage 4 pressure ulcer, peripheral vascular disease, and contractures had a care plan for potential pressure injury development that required monitoring and documenting changes in skin status, including wound size and stage. A Braden Scale in early January 2026 showed low risk, but there were no weekly skin assessments documented from late January to early February. On February 9, the wound nurse documented an ulcer to the posterior left knee with a history of recurrent yeast rash and noted that a recent course of nystatin powder had not healed the area. A treatment order for mupirocin and a clean dressing was started the next day. The wound nurse stated that during treatment on February 9 the resident reported pain behind the left knee, prompting a deeper inspection that revealed a white area she believed looked like an ulcer, with tendon exposed and yellow drainage, but no wound assessment with measurements or staging was documented at that time. A weekly wound assessment and Wound PA note dated February 18 documented a stage 4 pressure ulcer with exposed tendon at the left posterior knee, with the PA stating the wound had been present for about two weeks and was caused by the tight contracture. The wound nurse acknowledged that the wound looked the same on February 9 and February 18 and that a full wound assessment with measurements should have been completed when the wound was first found.

Across these three residents, multiple staff interviews described a prior process in which NAs performed skin checks during baths or showers, documented findings on shower sheets, and were expected to notify nurses of abnormalities, while nurses and unit managers did not consistently review shower sheets or perform routine weekly skin assessments. The wound nurse and unit managers reported that Braden Scales were supposed to be completed on admission, quarterly, and with changes in condition or new wounds, but acknowledged that Braden assessments were missed for extended periods for at least two residents, coinciding with a transition to a new combined quarterly nursing assessment. Staff, including the Wound PA, physician, DON, wound nurse, and unit managers, stated that skin assessments should be completed by nurses at least weekly and that wounds should be assessed, measured, staged, and documented when identified, but this did not occur consistently for the residents cited in the deficiency.