Failure to Document Use and Monitoring of Low Air Loss Mattress
Penalty
Summary
The facility failed to ensure complete and accurate documentation for a resident who was prescribed a Low Air Loss (LAL) mattress for wound care and management. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD), was dependent on staff for all activities of daily living and had moderately impaired cognition. A physician's order required the use and monitoring of the LAL mattress every shift. However, review of the Treatment Administration Record (TAR) for January 2025 revealed that documentation regarding the use and monitoring of the LAL mattress was missing for several shifts. During interviews, the treatment nurse confirmed that the TAR lacked documentation for the specified dates and shifts, and was unable to explain why the licensed nurses had not completed the required entries. The DON stated that staff are required to check off and sign the TAR immediately after performing treatments as per physician's orders, and that the LAL mattress should be monitored every shift to ensure it is functioning correctly. The facility's policy indicated the use of pressure-reducing mattresses to prevent or minimize skin pressure. The lack of documentation resulted in the resident's medical record being incomplete.