F0686

D

Failure to Accurately Assess and Prevent Pressure Injuries for a High-Risk Resident

Scranton, Pennsylvania Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to accurately assess a resident’s pressure injury risk, implement appropriate preventive interventions, and conduct timely and thorough skin assessments, which contributed to the development of an unstageable pressure injury. Upon admission, the resident had multiple risk factors, including muscle weakness, difficulty walking, dependence on staff for bed mobility and transfers, incontinence, and moisture-associated skin issues. The admission nursing evaluation documented redness and rashes on the penis, groin, buttocks, sacrum, coccyx, and heel, but the clinical record did not include required details such as type of skin impairment, size, drainage, odor, or tissue characteristics, contrary to the facility’s wound management policy. Hospital records prior to admission had already identified moist, macerated skin with bleeding in the groin and penis area, blanchable redness on the coccyx, buttocks, and gluteal folds, and high risk for further skin breakdown, with specific recommendations for a low air loss bed, barrier products, avoidance of briefs, frequent repositioning, and use of a waffle cushion.

The facility’s Braden Scale assessments were inconsistent with the resident’s documented functional status and known risk factors. On admission, staff scored the resident at low risk (Braden score 18), documenting no sensory impairment, the ability to move freely with minimal assistance, and only often moist skin, despite other records showing the resident required maximal assistance for bed mobility and transfers and could not independently reposition in bed or chair. A subsequent Braden assessment again scored the resident as low risk (score 16), indicating the resident could make occasional position changes without assistance and move freely with minimal help, even though therapy evaluations documented extensive to maximal assistance needs for sit-to-stand transfers, bed mobility, and transfers. Based on the resident’s actual condition and the presence of moisture-associated skin damage, the Braden categories for mobility, moisture, and activity should have reflected greater impairment, and a more accurate score would have placed the resident in a high-risk category.

Progress notes later documented that the resident was at risk for skin breakdown due to moisture-associated skin areas, limited mobility, and incontinence, yet the interventions focused on educating the resident to reposition himself frequently, despite documentation that he was moderately cognitively impaired and unable to reposition without staff assistance. These notes did not reflect a change in approach to account for the resident’s dependence on staff. Eventually, a progress note documented the discovery of an unstageable pressure injury on the right gluteal area measuring 3 cm x 3 cm x 0.1 cm, with 100% purple, non-blanching tissue. At that time, the record referenced a low-air loss mattress order and continued two-hour repositioning, but prior to the development of this wound, the facility had not accurately assessed the resident’s pressure injury risk or fully implemented the recommended pressure-relieving and moisture-management interventions identified in the hospital records and required by facility policy.

The facility’s own wound management/pressure reduction policy required comprehensive risk assessment using the Braden scale on admission and weekly for four weeks, weekly body checks by CNAs, and detailed documentation of any skin impairment, including location, size, description, drainage, odor, and necrosis. The policy also required specific actions when an unstageable pressure ulcer is identified, such as moist saline dressings, consultation with the wound nurse, physician, and dietician, and use of prevention or specialty mattresses as needed. In this case, the initial and subsequent Braden assessments did not reflect the resident’s true risk level, the admission skin findings were not documented in the detailed manner required, and the preventive interventions recommended by the hospital wound care provider were not fully implemented prior to the development of the unstageable pressure injury. These actions and omissions formed the basis of the cited deficiency under 28 Pa. Code 211.10(d) and 211.12(c)(d)(1)(3)(5).