Failure to Obtain Physician Order and Monitor Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a physician's order and appropriate monitoring were in place for a Low Air Loss (LAL) mattress used as a pressure ulcer intervention for a resident with multiple complex medical conditions. The resident's diagnoses included acute respiratory failure with hypoxia, dysphagia, unstageable pressure ulcer of the sacral region, stage 3 pressure ulcer of the left lower back, hemiplegia, and pressure-induced deep tissue damage. During observation, the resident was found resting on a LAL mattress, but review of the Treatment Administration Record (TAR) revealed there was no physician's order for the LAL mattress, nor was there documentation of monitoring the mattress for effectiveness or correct settings. Interviews with the treatment nurse and the Assistant Director of Nursing confirmed that the LAL mattress was in use without a physician's order and that the TAR did not reflect its presence or monitoring. The facility's policy required documentation of current treatments, including support surfaces, and review of their pertinence to the resident's condition. The lack of a physician's order and absence of monitoring for the LAL mattress meant that the intervention was not properly individualized or tracked for effectiveness, as required by facility policy.