Failure to Provide Proper Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for one resident. During wound care, licensed vocational nurses did not apply barrier cream to the resident's sacrum as ordered by the physician. Additionally, the wound care assessment did not document the presence of undermining in the sacrococcyx pressure injury, despite direct observation of undermining from 8 o'clock to 12 o'clock. The nurses involved did not initially recognize or document the undermining, and the physician was not notified of this change in the wound's condition at the time of assessment. The resident, who had a diagnosis of anoxic brain damage and was non-verbal, was dependent for mobility and had a documented stage 4 pressure injury to the sacrum. Medical records and care plans indicated the need for regular assessment, documentation, and communication regarding the wound's status, including the presence of undermining. However, the initial admission record lacked measurements and staging of the pressure injury, and subsequent skin evaluations did not address the undermining observed during wound care. Furthermore, the facility did not ensure that the low air loss mattress (LALM) settings were correctly adjusted according to the resident's weight. The mattress was set for a weight of 180 pounds, while the resident weighed 116 pounds. This discrepancy was confirmed by both nursing staff and the Director of Nursing, who acknowledged that the mattress settings should correspond to the resident's actual weight as part of wound management interventions.