Failure to Revise Care Plan for Use of Low Air Loss Mattress
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to specifically address the use of a low air loss (LAL) mattress, which is a specialized device used to prevent and treat pressure ulcers. The resident in question had significant medical conditions, including metabolic encephalopathy, hemiplegia, and cerebral infarction, and was assessed as being at risk for developing pressure ulcers. The resident was dependent on staff for activities of daily living and lacked the capacity to make decisions. The care plan in place addressed the risk for skin breakdown and included general interventions such as assessing risk and using pressure-relieving devices as needed, but did not specify the type of device to be used. During a review of the care plan and interviews with facility staff, it was confirmed that the care plan had not been updated to reflect the use of the LAL mattress for this resident. The Assistant Director of Nursing acknowledged that the care plan lacked specificity regarding the pressure-relieving device, which was necessary for consistent and individualized care. Facility policy required that care plans be revised as residents' conditions changed, but this was not done in this case.