Failure to Ensure Functioning Pressure-Relieving Device for Resident with Pressure Ulcer
Penalty
Summary
A deficiency occurred when a resident with a history of kyphosis, lordosis, and lumbar vertebra compression fracture developed a pressure ulcer on her spine, reportedly caused by her bra rubbing. The resident's care plan included the use of a reactive air mattress as a pressure-relieving intervention to promote healing and prevent further skin breakdown. However, during observation, it was found that the reactive air mattress was not functioning while the resident was in bed. Further investigation revealed that the LPN assigned to the resident was unaware of how to operate the air mattress and did not know how long it had been nonfunctional. Maintenance staff confirmed the mattress was not working and had not been notified of the issue. The Chief Nursing Officer acknowledged that there was no process in place to ensure the proper functioning of reactive air mattress units, resulting in the resident not receiving the ordered pressure-relieving intervention.