Failure to Obtain Physician Order and Monitor Specialty Mattress Settings for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a stage 3 pressure ulcer, not present on admission, was found to be using a specialty air mattress without a physician's order specifying the mattress settings. The resident's care plan included interventions such as the use of a pressure redistribution surface and regular repositioning, but there was no documentation of a physician's order for the mattress or instructions regarding its settings and monitoring. During observations and staff interviews, it was revealed that licensed staff were unable to locate any physician order or guidance for the air mattress settings, despite facility policy requiring such an order and regular monitoring by nursing staff. The facility's policy also stipulated that the mattress settings should be adjusted according to manufacturer recommendations and checked by a licensed nurse, which was not documented as being done for this resident.