Failure to Implement and Monitor Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to ensure proper use of pressure-reducing equipment and interventions for two residents at risk for pressure ulcers. One resident, with a history of pressure ulcers, limited mobility, and a low body weight, was observed with her low air-loss mattress set incorrectly at a much higher weight than her actual weight and, on one occasion, with the mattress deflated and the control panel turned off. Staff interviews revealed uncertainty about why the mattress was off and inconsistent practices regarding checking and setting the mattress according to the resident's weight, despite facility policy requiring these checks each shift. Another resident, who was dependent on staff for all activities of daily living and had multiple medical conditions including hemiparesis, dementia, and a history of skin breakdown, was observed multiple times lying in bed with his heels directly on the mattress, despite care plan instructions and physician orders for the use of heel protector boots to offload pressure. The boots were found on the bed or bedside table rather than on the resident. Staff interviews indicated that both nurses and CNAs were aware of the need to float the resident's heels or apply boots, but the intervention was not consistently implemented. The facility's policies required identification and implementation of preventative interventions for residents at risk for pressure injuries, as well as ongoing monitoring to ensure effective prevention and care. However, the observed failures to use pressure-relieving devices as intended and to follow care plan interventions for both residents constituted deficiencies in pressure ulcer prevention and care.