Failure to Ensure Proper Use of Pressure-Relieving Devices for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that two residents at risk for pressure ulcers received appropriate care related to the use of low air-loss mattresses and pressure-relieving devices. For one resident with multiple diagnoses including obesity, schizoaffective disorder, and limited mobility, the low air-loss mattress was not set to the correct weight according to the manufacturer's guidelines. The mattress remained set at a higher weight than the resident's actual weight for several days, and staff reported that they only checked the mattress if an alarm sounded, relying on the equipment provider to set and manage the settings. The resident's care plan did not include specific instructions regarding the mattress settings. For another resident with multiple chronic conditions such as multiple sclerosis, diabetes, and obesity, the low air-loss mattress was observed to be set at a generic setting, and pressure-relieving boots intended to protect the resident's heels were not applied while the resident was in bed. The boots were found at the bottom of the bed on multiple occasions, leaving the resident's heels in direct contact with the mattress. Staff interviews revealed inconsistent practices regarding monitoring and application of pressure-relieving devices, and there was no documentation or sign-off process to ensure the correct use of the mattress or boots. Additionally, the facility was unable to provide a policy related to pressure ulcer prevention and care when requested. Both residents' care plans lacked direction for staff to monitor or adjust the low air-loss mattress settings, and there was no evidence of routine checks or documentation to ensure that pressure-relieving interventions were consistently implemented as required.