Failure to Ensure Proper Pressure-Relieving Mattress Settings for Resident with Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a stage 2 sacral pressure ulcer received care consistent with professional standards of practice, specifically regarding the use of a pressure-relieving mattress. The resident, a 97-year-old female with multiple diagnoses including severe cognitive impairment, hemiplegia, contractures, and muscle wasting, was identified as being at risk for pressure ulcers and had an active stage 2 sacral ulcer. Her care plan included the use of a pressure-relieving mattress, regular repositioning, wound care, and nutritional support. Despite these interventions being documented, observations over several days revealed that the resident's pressure-relieving mattress was consistently set at a weight setting of 360 pounds, while her actual weight ranged from approximately 134 to 141 pounds. Multiple staff interviews indicated a lack of clarity regarding responsibility for ensuring the mattress was set correctly according to the resident's weight. Nursing staff, the treatment nurse, the ADON, the DON, and the administrator all acknowledged that the mattress should be set based on the resident's weight and that incorrect settings could negatively impact skin integrity and wound healing. Facility policies reviewed indicated that support surfaces should be selected and set based on individual resident factors, including weight, to prevent skin breakdown. However, the failure to ensure the mattress was set appropriately for the resident's weight represented a lapse in following these policies and professional standards, potentially compromising the effectiveness of the pressure-relieving intervention for this resident.