Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure ulcers for a resident identified as being at very high risk. Specifically, the resident, who had a history of hemiplegia, hemiparesis, muscle wasting, and was dependent on staff for most activities of daily living, was found to have a low air loss (LAL) mattress set at 350 pounds, despite their actual weight being 144.4 pounds. This incorrect setting was not in accordance with the physician's order, which required the mattress to be set according to the resident's weight and monitored daily. Staff interviews confirmed that an improperly set mattress could be too hard and increase the risk of pressure ulcer development. Additionally, the resident's medical record did not contain a care plan addressing their risk for pressure ulcer development, despite assessments indicating a very high risk and facility policy requiring individualized care plans for such risks. The Director of Nursing confirmed the absence of a care plan and acknowledged that one should have been in place to guide staff interventions. Facility policies reviewed also emphasized the need for appropriate support surfaces and comprehensive care planning for residents at risk of skin breakdown, which were not followed in this case.