Failure to Implement Ordered Pressure Relieving Intervention
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that pressure relieving interventions were implemented for a resident identified as being at risk for pressure injuries. The resident had a Braden Scale assessment indicating risk for pressure injuries and a physician's order for an air mattress while in bed. Despite this, on multiple occasions over two days, the resident was observed in bed with the air mattress pump turned off, as confirmed by both direct observation and staff interview. The air mattress pump, intended as a preventive intervention, was not in use while the resident was in bed, contrary to the physician's order and the resident's care needs.