Failure to Ensure Correct Support Surface Settings for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified when a resident with a history of pressure ulcers was observed with a specialized support surface (air mattress) that was not set according to the resident's current weight, as required by professional standards and the facility's own policy. Multiple observations revealed that the mattress setting remained incorrect over several days, despite staff documentation indicating that checks had been completed. The resident and staff interviews confirmed that the mattress was not set to the appropriate weight, and that this setting is critical for the prevention and healing of pressure ulcers. Record review showed that the resident was admitted with a pressure ulcer and had care plans and physician orders specifying the need for a support surface set to the resident's weight. Documentation in the Treatment Administration Record (TAR) indicated that staff were to check the mattress setting every shift, but the setting was not properly adjusted or maintained. Staff interviews further confirmed that the mattress was not set correctly and that the importance of proper settings was understood, yet the deficiency persisted. Facility policy required that support surfaces be used in accordance with evidence-based practice and manufacturer recommendations, including correct weight settings. Despite these requirements, the resident's mattress was not set as ordered, and staff failed to ensure the setting was correct, as evidenced by both direct observation and staff statements. This failure to follow professional standards and facility policy resulted in the identified deficiency.
Plan Of Correction
Treatment/Svcs to Prevent/Heal Pressure Ulcer CFR(s): 483.25(b)(1)(i)(ii) 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident 32 was assessed by the [R] room to ensure the [R] setting was corrected. The [R] completed a [R] on R32. It was unremarkable with no signs of [R]. The Director of Nursing and Unit Managers conducted a facility-wide audit to ensure that all low air loss mattresses were set to the correct settings with no findings of any additional low air loss mattresses being on the wrong setting. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: All residents have the potential to be affected by this deficient practice. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Director of Nursing or designee in-serviced licensed nursing staff and certified nursing aides on the center's policy for support services, low air loss mattresses being set to the correct weight setting, and confirming the settings being checked through documentation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are lasting: The Director of Nursing or designee will conduct audits on 10 residents on low air loss mattresses to ensure all are set on the correct settings. Audits will be conducted weekly x 4 weeks, then every other week for 4 weeks, and then monthly x 3 months. The results of the audit will be reported to the facility QAPI committee until compliance is determined to be sustained.