Failure to Provide Pressure Redistribution Cushion for Resident with Pressure Ulcers
Penalty
Summary
A deficiency occurred when staff failed to ensure that a pressure redistribution cushion was in place for a resident with stage 2 pressure ulcers. The resident, who had diagnoses including dementia, repeated falls, and chronic pain syndrome, was identified as being at risk for pressure ulcers and required a pressure-reducing device for her chair according to her care plan. Observations revealed that the resident's chair cushion was not in use and was instead found on the floor beside the chair on two separate occasions. The resident's daughter reported that the cushion had been soiled the previous day, and staff had removed the cover for washing, leaving the cushion on the floor. Further review of the resident's clinical record and care plan confirmed the need for a Roho cushion in the chair or wheelchair as an intervention to prevent skin breakdown. Despite this documented requirement, the resident was observed sitting in a wheelchair without the necessary cushion, and the facility's policy stated that all residents utilizing a wheelchair should have a pressure redistribution cushion. The Executive Director confirmed that it was nursing's responsibility to ensure the cushion was in place.