Failure to Prevent and Accurately Document Pressure Ulcers and Support Surface Use
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development or worsening of pressure injuries for three residents. For one resident, licensed nurses inaccurately documented the presence of pressure injuries on the buttocks when the actual condition was moisture-associated skin damage (MASD) to the coccyx. This discrepancy was confirmed through interviews and direct observation, where no pressure injury was found, and both the RN and DON acknowledged the documentation errors. Another resident was found to have a low air loss (LAL) mattress set incorrectly according to both the physician's order and the resident's weight. The mattress was set at a higher level than ordered and not in accordance with the manufacturer's guidelines for the resident's actual weight. Additionally, this resident's care plan required repositioning at least every two hours, but documentation showed that repositioning was not performed as frequently as required. Staff interviews revealed that the CNA was unable to reposition the resident due to difficulty and did not notify licensed nurses, and the DON confirmed that staff should have reported this issue. A third resident was observed lying on a LAL mattress that was set on static mode and at a weight setting inconsistent with the resident's actual weight and the physician's order. Staff interviews confirmed that the mattress should have been on alternate mode and set according to the resident's weight. The DON and RN verified that the mattress settings were not checked daily as required, and that the discrepancies undermined the intended preventative function of the support surface.