Failure to Complete and Document Weekly Skin Audits and Maintain Proper Air Mattress Settings
Penalty
Summary
The facility failed to ensure that weekly skin audits were completed and documented according to facility policy for two residents with pressure ulcers. For one resident with peripheral vascular disease, obesity, and diabetes, there was no physician's order for weekly skin checks until after surveyor inquiry, and the clinical record lacked documentation that weekly skin checks were being performed. Interviews with clinical staff confirmed that weekly skin checks were expected but not documented, and the facility's policy required these checks to be completed and recorded on shower days. The care plan for this resident also required weekly assessment of the pressure ulcer, but there was no evidence this was done. For another resident with spina bifida, hearing loss, and kidney disease, who had a stage 4 facility-acquired pressure ulcer, weekly body audits were inconsistently documented, with several weeks missing documentation over multiple months. The resident had a physician's order for a low air loss mattress set to a specific weight, but observations revealed the mattress was frequently set incorrectly, sometimes far above or below the resident's actual weight. The resident reported intermittent mattress function and communication barriers with staff, and staff interviews revealed that mattress settings were not always checked as required, with some staff signing off on checks without verifying the actual settings. Facility policies required that skin checks be completed and documented by nurses on shower days, and that air mattress settings be verified per physician's orders and checked every shift. However, documentation and staff interviews indicated these procedures were not consistently followed. There was also no documentation or care plan addressing the resident's reported habit of changing mattress settings, and staff were sometimes unaware of changes or malfunctions in the mattress equipment.