Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's pressure ulcer prevention and care practices. One resident was seen sitting in a wheelchair for an extended period without a pressure-relieving cushion, despite having a care plan indicating actual skin integrity impairment and an MDS assessment identifying risk for pressure ulcers. The registered nurse confirmed that a cushion was needed to prevent pressure ulcers, but the resident was left without one during the observations. Two other residents were found lying on low air loss mattresses that were not set up according to manufacturer instructions or facility policy. One resident's mattress was set at a weight significantly higher than the resident's actual weight, which staff acknowledged would make the mattress too firm and ineffective for pressure redistribution. Both residents had multiple layers, including folded blankets and extra sheets, placed between them and the mattress, contrary to both the facility's policy and the mattress manufacturer's guidelines, which specify only a thin sheet should be used. The records for these residents documented significant risk factors for pressure ulcers, including diagnoses such as vascular dementia, severe protein-calorie malnutrition, hemiplegia, and impaired mobility. Care plans and physician orders specified the use of pressure-reducing devices and preventive measures, but these were not properly implemented. Staff interviews confirmed that the observed practices did not align with facility policy or clinical guidelines for pressure ulcer prevention.