F0677Actual harm
ADL care
Provide care and assistance to perform activities of daily living for any resident who is unable
Residents affected
Few
Narrative
Resident #R187 was admitted with a Stage 2 pressure ulcer on the sacrum. Treatment record showed inconsistent application of the prescribed dressing — three of seven scheduled changes in the past week were not documented. Wound care nurse interview confirmed staffing shortfalls on weekend shifts contributed to the missed changes.