Failure to Ensure Pressure Reducing Mattress Was Used as Ordered
Penalty
Summary
A deficiency occurred when staff failed to implement physician-ordered interventions to prevent skin breakdown for a resident at risk for pressure ulcers. The resident, who had diagnoses including dementia and mobility issues, was observed in bed with the pressure reducing mattress machine turned off. The resident confirmed the machine was off and could not recall when it was last on or when staff last assisted her out of bed. A CNA also observed the machine was off and acknowledged it should be on but did not turn it on. Later, an LVN entered the room, plugged in the machine, and turned it on, stating it should always be on to prevent the mattress from deflating. Review of the resident's Braden Scale Assessment indicated she was at risk for developing pressure sores, and her care plan included the use of a physician-prescribed pressure reduction mattress. Physician orders specified the mattress should be set to alternating mode, with settings checked for functionality every shift. Despite these orders and care plan interventions, the pressure reducing mattress was not in use for an unknown period, as confirmed by multiple staff and the resident, resulting in a failure to follow prescribed interventions for pressure ulcer prevention.