Failure to Ensure Functioning Pressure-Relieving Mattress for At-Risk Resident
Penalty
Summary
A resident identified as being at risk for pressure ulcers was observed in bed with a low air loss mattress (LALM) that was not functioning, as the mattress was almost flat and the power was off. The Assistant Director of Nursing confirmed that the machine was not working due to the power being off and indicated that the mattress would not function unless the power was turned on. The resident's care plan and physician orders specified the use of a pressure-reducing mattress as an intervention for pressure ulcer prevention, and the facility's guidelines require adherence to such interventions for residents at risk. The resident's medical history included diagnoses such as protein calorie malnutrition, venous insufficiency, dementia, muscle wasting and atrophy, poly-osteoarthritis, and dermatitis, all of which increase the risk for pressure ulcers. The resident was assessed as being at risk for pressure ulcers, and the care plan included the use of a pressure-reducing mattress. Despite these documented needs and interventions, the required equipment was not operational while the resident was in bed, constituting a failure to provide appropriate pressure ulcer prevention as ordered.