Failure to Ensure Use and Documentation of Pressure-Reducing Mattress
Penalty
Summary
The facility failed to ensure that a pressure-reducing mattress was used every shift for a resident with significant risk factors for skin breakdown, as ordered by the physician and outlined in the care plan. The resident, who was admitted with diagnoses including Huntington disease and anemia and was noted to be severely impaired in thought process, developed an open area on the right buttock. Documentation revealed that the order for a pressure-reducing mattress was not consistently signed off in the treatment administration record, indicating that the intervention may not have been provided or verified as required. During interviews and record reviews, it was confirmed that the pressure-reducing mattress order was incorrectly documented in the medication administration record instead of the treatment administration record, and there were missing signatures from the treatment nurse responsible for checking the mattress settings each shift. Facility policy requires that all services provided and changes in the resident's condition be documented in the medical record to ensure communication among the care team. The lack of documentation and verification of the pressure-reducing mattress intervention constituted a failure to provide appropriate pressure ulcer care and prevention.