Failure to Provide Physician-Recommended Pressure-Reducing Mattress
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including stage three pressure ulcers, was not provided with the pressure-reducing intervention recommended by the wound care physician. The resident's care plan and wound evaluations documented the need for a low air loss mattress to aid in the healing of a stage three pressure ulcer. Despite these recommendations, there was no physician order for a low air loss mattress, and progress notes did not indicate that such a mattress was in use. Direct observations confirmed that the resident was lying in bed on the affected hip without a low air loss mattress in place. Interviews with staff verified the absence of the recommended mattress. The facility's own policy required that appropriate interventions be initiated for residents at risk of skin breakdown, and that wound treatments be supported by physician orders, but these steps were not followed in this case.