Failure to Provide Low Air Loss Mattress for High-Risk Resident with Pressure Ulcers
Penalty
Summary
The facility failed to implement a low air loss mattress for a resident with significant risk factors and existing pressure ulcers, despite repeated recommendations from the Wound Nurse Practitioner (NP). The resident, who had diagnoses including diabetes, muscle wasting, chronic kidney disease, and peripheral vascular disease, was admitted with pressure ulcers and was assessed as being at high risk for further skin breakdown due to immobility, malnutrition, and atrophy. The Wound NP consistently recommended a low air loss mattress from admission onward, and this recommendation was documented in multiple progress notes over several months. Despite these recommendations, the resident was only provided with a standard pressure reducing mattress, not a low air loss mattress, as confirmed by observations and staff interviews. The care plan and physician orders referenced pressure reducing surfaces and other interventions such as heel protectors and offloading, but did not specifically address the use of a low air loss mattress as recommended by the Wound NP. The resident subsequently developed a new deep tissue injury (DTI) on the left heel, which later declined to an unstageable pressure ulcer with slough and drainage, as documented in wound tracking and progress notes. Interviews with nursing staff and the Wound NP confirmed that the low air loss mattress was never provided, despite ongoing recommendations and the resident's continued risk and wound deterioration. Facility policy indicated that specialized surfaces, including low air loss mattresses, should be selected based on risk assessment and specialist recommendations, but this was not followed in this case. The failure to implement the recommended intervention contributed to the resident's ongoing wound issues and the development of a new pressure injury.