Failure to Provide Ordered Pressure-Relieving Mattress for High-Risk Resident
Penalty
Summary
The facility failed to implement wound care recommendations for a resident who was at high risk for pressure ulcer development. The resident, who had diagnoses including lymphedema, chronic kidney disease, and obstructive uropathy, required substantial to maximal assistance for bed mobility and had impairments in both lower extremities. The care plan and wound care progress notes specified the need for an alternating pressure/low air loss mattress to prevent skin breakdown and pressure ulcers, with instructions to ensure the mattress settings were appropriate for the resident's needs. Despite these documented interventions, observation and staff interviews confirmed that the resident did not have the recommended mattress in place. The resident had a history of chronic wounds and pressure ulcers, and was noted to be at high risk for further pressure ulcer formation due to decreased mobility, incontinence, and limited ability to reposition. Facility policy required regular review of skin assessments and compliance with interventions, but the lack of the prescribed mattress indicated a failure to follow these protocols. The deficiency was identified through observation, interviews, and medical record review, affecting one of three residents reviewed for pressure ulcers.