Failure to Provide Timely Repositioning and Correct Pressure Mattress Settings for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatments and services to promote wound healing and prevent the development of pressure ulcers for two residents who were at risk. For one resident with a history of decubitus ulcers, tracheostomy dependence, and anoxic encephalopathy, documentation showed that repositioning was not performed or recorded every two hours as required by the care plan and facility policy. Specific gaps in repositioning were noted, including periods of 3.5 hours and over 9 hours without documented turns. The Director of Nursing confirmed that these lapses occurred and that elevating the head of the bed did not count as repositioning. Another resident, who had diagnoses including obesity, encephalopathy, tracheostomy, and a gastric feeding tube, was also not repositioned according to the prescribed two-hour schedule. Observations revealed that the resident remained on the same side for over three and a half hours, despite the turning schedule indicating otherwise. Staff interviews confirmed that the resident was not turned as required, and the care plan and facility policy both specified the need for repositioning every two hours for pressure ulcer prevention. Additionally, the same resident was found to be using a low air loss mattress that was programmed for an incorrect weight range, significantly higher than the resident's actual weight. Nursing staff were unaware of the incorrect setting, and it was acknowledged that the mattress should have been set to match the resident's weight to function properly. Facility policy required the consistent use of pressure-reducing devices as ordered, and staff confirmed the importance of correct mattress settings for effective pressure redistribution.