Failure to Ensure Proper Use of Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The facility failed to provide appropriate treatments and services to prevent the development and promote the healing of pressure ulcers for four residents. For two residents, the low air loss mattresses (LALM) intended for wound management and prevention were found to be set on static pressure rather than alternating pressure, contrary to physician orders and manufacturer instructions. Observations confirmed that the static mode was engaged during times when the residents were not receiving care, and documentation of LALM settings was missing for certain shifts. Staff interviews confirmed that leaving the mattress on static mode could prevent wound healing and increase the risk of skin breakdown, especially for residents unable to reposition themselves. Another resident, who was dependent for activities of daily living and mobility, did not have prescribed heel boots in place for offloading purposes as ordered by the physician. The absence of heel protectors was observed during a room check, and staff acknowledged the importance of following physician orders to prevent pressure ulcers, particularly for residents with limited mobility and increased risk of skin breakdown. Facility policy also emphasized the need to "float heels" or use protective devices as recommended by clinical staff or the physician. Additionally, a fourth resident was found lying on a bariatric LALM that was set at a weight significantly higher than the resident's actual weight. Staff interviews indicated that incorrect mattress settings could compromise the effectiveness of pressure redistribution, increasing the risk of skin breakdown. The resident's physician order required monitoring of proper mattress functioning and placement every shift, but the observed setting did not match the resident's documented weight. Facility policy and the user manual for the mattress system both highlighted the importance of correct settings for optimal support and pressure relief.
Plan Of Correction
F686: Treatment/Service to prevent/heal Pressure ulcer CORRECTIVE ACTION On 3/7/2025, LALM setting was corrected for residents 36, 20, and 16. On 3/7/2025, offloading boots were put on resident 1's feet. OTHER RESIDENTS AFFECTED IDENTIFICATION On 3/7/2025, the treatment nurse and licensed nurses checked all residents with LALM and offloading boots to verify that they are being utilized as ordered. No other residents were affected by the deficient practice. MEASURES AND SYSTEMIC CHANGES On 3/21/2025, DON/Treatment nurse provided an in-service training to licensed nurses on how to operate air loss mattress for correct setting. DON/designee will randomly check residents' LALM setting weekly to verify that they are correctly set per MD orders. DON/designee will randomly check residents with offloading boots orders if they are properly carried out. MONITORING PERFORMANCE DON/Designee will report findings and trends to the monthly QAA meeting for further recommendations for 3 months or until substantial compliance is met.