Failure to Provide Ordered Low Air-Loss Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a low air-loss mattress, as ordered by the physician and documented in the care plan, was in place for a resident with an unstageable sacral pressure ulcer and functional quadriplegia. Despite orders and care plan directives for the use of a low air-loss mattress to aid in skin management and wound healing, the resident was found to have a regular mattress on her bed. The resident reported concerns about the mattress settings to a CNA, who confirmed the absence of the air-loss mattress. Interviews with the treatment nurse and a licensed nurse revealed that both were unaware the mattress had been missing for weeks, and that nurses had been signing off on the Treatment Administration Record (TAR) for the mattress placement and settings without verifying its presence or function. Record reviews showed that the care plan and physician's orders required monitoring of the low air-loss mattress every shift, but this was not done. The DON acknowledged that the mattress may have been switched to another bed and confirmed the importance of the air-loss mattress for the resident's multiple skin issues. The facility's policy required the implementation of interventions for pressure ulcer prevention and treatment, but these procedures were not followed, resulting in the resident not receiving the prescribed pressure ulcer care.