Failure to Obtain Physician Order for Bolster Low Air Loss Mattress
Penalty
Summary
A deficiency occurred when a resident with a history of a sacral pressure ulcer, abnormal posture, and muscle weakness was provided with a bolster low air loss mattress (LALM) without a corresponding physician's order. The resident was assessed as being at moderate risk for pressure sores, requiring substantial to maximal assistance with daily activities, and was observed using the bolster LALM in bed. Staff interviews confirmed that the mattress was in use to prevent the resident from sliding or falling out of bed, but review of the resident's active orders revealed that only a standard low air loss mattress was ordered, not the bolster version. Further interviews with nursing staff and the DON confirmed that the decision to use the bolster LALM was made by the interdisciplinary team for the resident's safety, but the specific order for this equipment was not documented in the physician's orders. Additionally, the facility was unable to provide a policy and procedure specific to the use of bolster low air loss mattresses, and the existing policy only addressed general air mattress use for pressure ulcer prevention and healing.