Failure to Monitor and Set Air Mattress as Ordered for Pressure Ulcer Care
Penalty
Summary
A resident with a history of Alzheimer's disease, dementia, and a pressure ulcer to the left buttocks was identified as requiring a pressure-reducing air mattress set at a specific setting of 280, as ordered by the physician and outlined in the care plan. Despite these orders, observations revealed that the air mattress was set at 160 instead of the required 280. Nursing staff, including an LPN, had signed off on the Treatment Administration Record (TAR) indicating the mattress was checked, but were unaware of the correct setting and had not verified it against the physician's order. The discrepancy was only discovered after the LPN reviewed the order and adjusted the setting accordingly. Further interviews with nursing staff and the Director of Nursing Services confirmed that the air mattress should have been set and monitored at the correct setting every shift, as per facility policy and physician orders. The facility's policies required pressure relief mattresses to be checked for proper function every shift, but this was not consistently done. The failure to maintain the correct air mattress setting and to verify compliance with physician orders contributed to the deficiency in pressure ulcer care for the resident.