Failure to Ensure Functionality of Pressure-Relieving Mattress for Resident with Pressure Wounds
Penalty
Summary
A resident with multiple pressure wounds was observed lying on an air-loss mattress that was not functioning due to being disconnected from the pump, as indicated by a continuous beeping alarm and lack of mattress inflation. Despite the alarm, staff, including a Certified Nurse Assistant and a Wound Care Nurse, did not address the malfunction during wound care. The resident was also found lying on two overlapping cloth pads and a sheet that were bunched up, which could further compromise pressure relief. The Wound Care Nurse believed the mattress was working properly, even though it was not. The resident had a recent history of readmission with multiple pressure wounds and was identified as being at risk for further skin breakdown, with care plans and physician orders specifying the use and regular monitoring of a pressure-reducing mattress. Documentation showed the development of a new deep tissue injury to the left buttock while under these interventions. Staff interviews confirmed that expectations included responding to and troubleshooting medical equipment alarms, but there was no specific facility policy regarding air-loss mattresses. The facility's general policy required the provision of support devices and assistance as needed for pressure injury prevention.