Failure to Follow Physician Orders for Air Mattress Settings in Pressure Ulcer Care
Penalty
Summary
The facility failed to follow physician's orders regarding air mattress settings for three residents who were at risk for or had existing pressure ulcers. Facility policy and physician orders required that air mattresses be set according to each resident's most recent weight, with a margin of plus or minus 10 pounds, and that the settings be checked and documented every shift. However, observations revealed that the air mattresses for these residents were set significantly higher than their current weights, contrary to the orders and policy guidelines. One resident with Parkinson's disease, dementia, and chronic kidney disorder, who was severely cognitively impaired and at risk for pressure ulcers, was observed multiple times with an air mattress set at 200 lbs despite a current weight of 122 lbs. Another resident, dependent for all activities of daily living and with an unstageable wound, had an air mattress set at 280–330 lbs while their most recent weight was 85 lbs. A third resident with diabetes and multiple deep tissue injuries had an air mattress set at 210–320 lbs, while their weight was 169.8 lbs, with staff acknowledging the setting should have been around 180 lbs. Interviews with the Director of Nursing and unit managers confirmed that the expectation was for staff to set air mattresses according to physician orders and resident weights. Despite this, repeated observations showed that the required settings were not being followed, and the air mattress settings were not adjusted to match the residents' current weights as specified in the orders.