Failure to Timely Provide Pressure Offloading Mattress Resulting in Stage 3 Pressure Ulcer
Penalty
Summary
A facility failed to ensure timely ordering and implementation of a pressure offloading mattress for a resident who was at moderate risk for pressure ulcer (PU) development and admitted with existing wounds. Upon admission, the resident had stage 2 PUs on the right and left buttocks and an unstageable PU on the left foot, but no skin breakdown on the coccyx. The initial care plan did not address existing pressure ulcers or include prevention interventions, and there was no documentation of a higher-level mattress being provided at admission. Despite the resident's risk factors and care needs, the care plan was not updated to include pressure ulcer prevention interventions until a week after admission, when a slit was first noted on the coccyx. The resident developed a stage 3 PU on the coccyx, which progressed to require wound vacuum treatment. Documentation showed inconsistent wound assessments and delayed implementation of a low air loss (LAL) mattress, which was not provided until approximately 30 days after the need was identified and the RCM was notified. Interviews with staff confirmed that there was no standard protocol for pressure ulcer prevention interventions upon admission, and staff were unclear about the process for ordering specialty mattresses. The delay in providing appropriate pressure relief measures contributed to the development and worsening of the resident's coccyx wound, which impacted the resident's rehabilitation and discharge potential.