Failure to Provide Appropriate Pressure Ulcer Care and Pressure-Relieving Devices
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and prevent new ulcers from developing for three residents reviewed for treatment and services related to pressure ulcers. For one resident with a stage 4 coccyx pressure ulcer, the low air loss mattress was set incorrectly at a weight of 280 pounds, despite the resident weighing approximately 160-180 pounds. The resident reported discomfort with the mattress, and staff interviews revealed uncertainty about who was responsible for setting and monitoring the mattress settings. Documentation showed that the mattress was supposed to be checked every shift, but the incorrect setting persisted. Two other residents with sacral or buttock wounds did not have functioning low air loss mattresses available to promote healing. Observations confirmed that these residents were in bed without the required pressure-relieving mattresses, despite having wounds that required such interventions. Staff interviews indicated a lack of clarity regarding the process for ordering and setting up low air loss mattresses, and the care plans did not consistently reflect the need for these devices as interventions for wound care. Additionally, one resident's wound dressing was not changed daily as ordered, and care plans lacked specific details about the type of pressure ulcer or treatment orders. Staff interviews revealed inconsistent knowledge about the purpose and management of low air loss mattresses, including who was responsible for ensuring correct settings and timely provision. The facility's policy required high-risk individuals to be placed on pressure-reducing devices, but this was not consistently implemented, resulting in residents being at risk for developing new or worsening pressure ulcers.