Failure to Follow Physician Orders for Air Mattress Settings in Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, for two residents with significant risk factors and existing wounds, staff did not follow physician orders regarding the settings of air mattresses, which are critical for pressure ulcer prevention and management. Observations revealed that one resident's air mattress was consistently set at 125 lbs, despite a physician order and care plan specifying a setting of 150 lbs. Another resident's air mattress was observed set at 340 lbs, while the physician order and care plan required a setting of 160 lbs. In both cases, the medical records, care plans, and physician orders clearly documented the required settings and the need for staff to check the mattress function and settings every shift. Interviews with nursing staff and the Director of Nursing confirmed that nurses are responsible for checking and maintaining the correct air mattress settings each shift, as per physician orders. However, staff acknowledged that the mattresses were not set according to the prescribed settings. The facility's policy also required licensed nurses to check powered support surfaces for proper functioning and inflation each shift and as needed. Despite these requirements, the observed discrepancies in mattress settings for both residents demonstrated a failure to follow established protocols and physician directives for pressure ulcer prevention and care.