The facility failed to perform required skin checks on two residents with documented risks for pressure ulcer development, missing assessments for weeks at a time despite physician orders and care plan requirements.
Resident #1, who has no cognitive impairment according to facility assessments, was identified as having potential for pressure ulcer development due to impaired mobility, bladder incontinence, and peripheral vascular disease that decreases blood flow. The resident's care plan, dated September 16, established a goal of maintaining "intact skin free of redness blister discoloration."
A physician order from August 1, 2024, specifically instructed staff to complete weekly skin checks every Thursday during the 7:00 AM to 3:00 PM shift for skin monitoring.
Despite these requirements, skin assessments for Resident #1 were not performed on July 24, July 31, August 14, August 21, August 28, September 4, September 11, September 18, October 2, and October 9. The facility's August and September Treatment Administration Records showed staff had signed documentation acknowledging the skin checks were completed.
A second resident, Resident #5, faced similar gaps in required care. Weekly skin assessments were skipped during the weeks of October 5, September 14, September 21, September 28, August 17, August 10, and August 3. No skin assessments were completed for this resident during the entire month of July.
When inspectors interviewed nursing staff on October 15, they found a consistent understanding of the computer system used to track and document skin assessments. Staff A, a Licensed Practical Nurse, explained that the facility's UDA computer system alerts nurses when skin checks are due and provides a platform for documentation.
"It will pop up on the UDA in the computer to let me know it is due," Staff A told inspectors. When asked about documentation, she said, "I will click on the UDA tab, and it will open up to the skin assessment for documentation."
The Unit Manager confirmed this process, stating that alerts appear on the UDA system when skin checks are due. "Also, I print out a list of the skin checks that are due for that day and highlight the names," the manager told inspectors.
Staff B, another Licensed Practical Nurse, provided similar information about the computer system's functionality. "It pops up on the UDA," she said when asked how she knows when residents need skin checks. For documentation, she explained, "In the assessment, I go to the resident that is due and choose skin assessment."
The systematic nature of the missed assessments raises questions about the reliability of the facility's documentation practices. Both residents had established care plans identifying their elevated risk for skin breakdown, yet the required preventive monitoring failed to occur consistently over multiple months.
Pressure ulcers represent a significant health risk for nursing home residents, particularly those with limited mobility or underlying medical conditions that compromise circulation. Regular skin assessments serve as a primary prevention strategy, allowing staff to identify early signs of breakdown before serious wounds develop.
The inspection findings indicate that while nursing staff understood the facility's computer system for tracking and documenting skin assessments, the actual physical examinations were not being performed as required. The discrepancy between signed treatment records and missing assessments suggests a breakdown in the facility's quality assurance processes.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the pattern of missed assessments over extended periods demonstrates a systematic failure to follow established care protocols designed to protect vulnerable residents from preventable injuries.
The facility's skin assessment protocols appeared well-designed on paper, with clear physician orders, detailed care plans, and a computer system designed to prompt staff when assessments were due. The implementation of these protocols, however, fell short of the documented requirements, leaving residents at unnecessary risk for pressure ulcer development.
Both residents affected by the missed assessments had medical conditions that specifically increased their vulnerability to skin breakdown, making the regular monitoring even more critical for their health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Port Saint Lucie from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Life Care Center of Port Saint Lucie
- Browse all FL nursing home inspections