Failure to Provide and Properly Set Pressure-Relieving Mattresses for At-Risk Residents
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention and care for several residents as ordered by their physicians and as outlined in facility policy. Specifically, three residents who were at risk for pressure ulcers due to immobility or other medical conditions were not provided with low air loss (LAL) mattresses as ordered. Observations and interviews confirmed that these residents were lying on regular mattresses despite having physician orders and care plans indicating the need for LAL mattresses to prevent pressure injuries. Staff interviews revealed a lack of awareness or follow-through regarding the implementation of these orders. Additionally, two residents who were provided with LAL mattresses did not have the mattresses set to the correct weight settings as required. In both cases, the mattress settings were significantly higher than the residents' actual weights, which staff acknowledged was not in accordance with manufacturer instructions or facility policy. Staff interviews confirmed that the incorrect settings could compromise the effectiveness of the mattresses in preventing pressure ulcers. The facility's own policies and procedures, as well as the manufacturer's operational manual, require that appropriate support surfaces be selected and maintained based on individual resident risk factors and that LAL mattresses be set according to the resident's weight. Despite these requirements, the facility did not ensure that the necessary equipment was provided or properly set for residents at risk for pressure ulcers, as evidenced by direct observation, record review, and staff interviews.