Failure to Provide Pressure Redistribution Cushion for At-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, limited mobility, and a history of incontinence and falls was not provided with a pressure redistribution cushion in his wheelchair, as required by his care plan and facility policy. The resident's medical records indicated diagnoses of dementia, benign prostatic hyperplasia, and acute kidney failure, and assessments consistently documented his risk for pressure ulcers due to incontinence and reduced mobility. The care plan specifically instructed staff to use pressure redistribution surfaces for the resident's bed and wheelchair if indicated, and the Braden Scale assessment confirmed his risk for developing pressure ulcers. Despite these documented risks and care plan instructions, observations on multiple occasions revealed that the resident was seated in his wheelchair without any cushion or pressure-reducing padding. Interviews with nursing staff and aides confirmed that the resident previously had a pressure-relieving cushion, but it was not present at the time of the observations, possibly due to issues with incontinence or falls. The facility's policy required implementation of preventative interventions, including pressure redistribution, for residents at risk, but this was not followed for the resident in question.