Failure to Provide Ordered Low Air Loss Mattress for Pressure Ulcer Care
Penalty
Summary
A resident with a history of a Stage 4 pressure ulcer, major depressive disorder, bradycardia, and sepsis was readmitted to the facility and had a physician's order for a low air loss mattress to address their pressure ulcer. The resident's Minimum Data Set indicated moderately impaired cognitive skills and a need for partial assistance with activities of daily living. Despite the physician's order, the resident was observed lying on a regular mattress during a facility visit. The Director of Nursing confirmed that the resident did not have the ordered low air loss mattress and acknowledged that no such mattresses had been ordered for any resident in the past two months. Facility policy required the use of specialty mattresses for residents with pressure injuries or those at risk. The failure to provide the prescribed low air loss mattress constituted a deficiency in pressure ulcer care for this resident.