Failure to Ensure Proper Pressure Ulcer Prevention and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for two residents. For one resident with a Stage 3 pressure injury on the sacrum, the low air loss (LAL) mattress was not set according to the resident's weight, as required by the manufacturer's guidelines. Observations showed the mattress was set significantly higher than appropriate for the resident's weight, and there was no documentation of regular monitoring of the mattress's functionality or placement, despite physician orders and facility policy requiring such monitoring. Another resident, identified as being at high risk for skin breakdown and with paraplegia, was also found to have deficiencies in pressure ulcer prevention. The LAL mattress for this resident was set above the recommended weight setting and was left in 'statique' mode, which is intended only for short-term use during care activities. Additionally, the resident's heel protectors, which were part of the care plan to prevent pressure injuries, were not in place while the resident was in bed. Staff interviews confirmed that the heel protectors had not been applied and that the mattress settings were not consistently checked or adjusted according to the resident's current weight. Facility policies required the use of pressure-reducing surfaces and adherence to manufacturer guidelines for support surfaces, as well as regular monitoring and documentation. However, the care plans and interventions for both residents did not include specific instructions for mattress settings or monitoring, and staff were unable to provide documentation of required checks. These failures were confirmed through observations, interviews, and medical record reviews.