Failure to Provide Ordered Pressure Redistribution Mattress for Resident with Pressure Injuries
Penalty
Summary
The facility failed to implement ordered wound care interventions for a resident with multiple pressure injuries. Upon observation, the resident was found in bed on a regular mattress, despite an active physician order and care plan intervention for a low air loss mattress to aid in pressure redistribution. The wound care nurse and technician confirmed that the resident had stage 2 pressure injuries on both buttocks, which were present on admission and required daily dressing changes. The nurse expressed concern about wound deterioration, noting an increase in wound size and peri-wound irritation with minor bleeding. The nurse also stated uncertainty regarding why the resident was not provided with the specialized mattress after a recent room change. Record review showed that the resident's wounds had been measured and documented by the wound physician, with a consistent order for a low air loss mattress since admission. The care plan identified the resident as being at risk for further skin breakdown and included interventions for pressure redistribution. Facility policy required implementation of individualized care plans and provision of low air loss mattresses for residents assessed as needing them. Despite these orders and policies, the resident was not provided with the required mattress, and wound deterioration was observed.