Failure to Provide Ordered Pressure-Reducing Device for At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident, identified as being at risk for pressure ulcers due to impaired mobility and incontinence, did not have a physician-ordered pressure-reducing cushion in place on their wheelchair. The resident's medical record documented diagnoses including difficulty walking, dementia, lack of coordination, muscle weakness, and a need for assistance with personal care. The care plan and assessments indicated the resident was at risk for pressure-related injuries and required monitoring and assistance with turning and repositioning. Despite a physician order for a cushion to be used in the wheelchair, multiple observations over several days found the resident's wheelchair lacked the required cushion, and no cushion was present in the room. Interviews with staff revealed inconsistent understanding and implementation of responsibilities regarding pressure-reducing devices. Certified Nurse Aides and Licensed Nurses stated that ensuring pressure-reducing devices were in place was a shared responsibility, and that such devices should be listed on the resident's care plan or Kardex. However, there was uncertainty among staff about which residents required these devices, and the ordered cushion was not in use as required by the resident's care plan and physician order. The facility's policy required pressure-reducing devices for individuals restricted to a chair, but this was not followed for the resident in question.