Failure to Provide LAL Mattress for Resident with Stage 3 Pressure Injury
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a pressure injury for one resident with a Stage 3 pressure injury. Despite the facility's policy and care plan indicating that a low air loss (LAL) mattress should be used for wound management in such cases, the resident was observed using a regular mattress. Multiple staff interviews confirmed that the resident did not have a LAL mattress upon admission and that there was no physician's order for one, even though it was facility protocol for residents with Stage 3 pressure injuries to have this intervention. Medical record review showed the resident was admitted with a Stage 3 pressure injury measuring 3 cm by 2 cm, and the care plan included an intervention for a LAL mattress. However, this intervention was not implemented, as verified by staff and direct observation. The failure to provide the LAL mattress as required by both the care plan and facility policy constituted a deficiency in the provision of necessary care and services for the resident's pressure injury.