Failure to Provide Consistent Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to ensure that two of three sampled residents at risk for pressure ulcers received consistent and appropriate pressure-reducing measures and repositioning, as required by their care plans and physician orders. For one resident, health records indicated a physician order for an air mattress to be set at alternate level 5, with staff required to check the settings every shift. However, observations revealed the air mattress was set at float level 8, and staff confirmed this was not in accordance with the order. The resident also reported that staff did not consistently reposition them every two to three hours as required, and continuous observation showed the resident remained lying flat on their back for several hours. Staff interviews confirmed that repositioning was not performed per the care plan instructions. For another resident, records showed a care plan and physician order for an air mattress to be set at 165 pounds with a specific cycle time, and staff were to check the settings every shift. However, staff discovered the bed was set incorrectly at 340 pounds, contrary to the physician order. Staff interviews confirmed that the air mattress settings were not being monitored and maintained as required. These failures were observed and confirmed through interviews and record reviews, demonstrating a lack of adherence to established protocols for pressure ulcer prevention and care.