Failure to Timely Implement Pressure Ulcer Prevention Intervention
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident at risk for pressure ulcers. The resident, who had multiple diagnoses including diabetes mellitus, abnormal posture, muscle weakness, osteoarthritis, heart failure, hypertension, and dementia, was dependent on staff for most activities of daily living and had severe cognitive impairment. The care plan, dated 2/6/25, specified the use of a Low Air Loss (LAL) mattress to prevent further decline in the resident's pressure ulcer condition. However, despite physician orders for the LAL mattress on multiple dates, the mattress was not installed until several days after a noted decline in the resident's pressure ulcer status. The delay in providing the LAL mattress was attributed to concerns from the resident's family about the risk of falls due to the increased bed height. The Director of Nursing confirmed that the mattress was not put in place until after the resident's condition had worsened. Facility policy required the provision of appropriate mattresses to residents at risk for skin breakdown, but this was not followed in a timely manner for this resident, resulting in a decline in the pressure ulcer.