Failure to Provide Ordered Pressure Ulcer Prevention Device Resulting in New Pressure Ulcers
Penalty
Summary
A deficiency occurred when a resident who was admitted with an unstageable pressure ulcer to the sacrum and identified as high risk for developing additional pressure ulcers did not receive care and treatment consistent with professional standards of practice. The resident, who was severely cognitively impaired, dependent for transfers and bathing, and incontinent of bowel and bladder, was ordered by the Wound Care physician to have a group two pressure reduction mattress (low air loss rotating mattress) as a preventive and therapeutic intervention. However, the resident continued to use a hospital-provided mattress overlay that did not offer the required pressure protection, as preferred by the family, and the ordered mattress was never implemented during the resident's stay. Despite the care plan and physician orders specifying the use of a low air loss mattress and interventions such as repositioning every two hours and offloading the heels, the resident was not provided with the prescribed mattress. Staff attempted to offload the resident's heels with pillows, but the resident, who was mobile in bed, consistently removed and discarded the pillows, leaving her heels exposed to the hard surface of the mattress overlay. This lack of effective offloading and failure to use the ordered pressure redistribution device contributed to the development of new pressure ulcers on both heels during the resident's stay. Interviews with the Wound Care physician, RN, and DON confirmed that the resident was never placed on the ordered low air loss mattress due to the family's insistence on using the hospital mattress. The facility's policy required systematic assessment and intervention for pressure injury prevention, including the use of appropriate support surfaces as ordered. The failure to implement the physician's order for a group two mattress and to ensure effective offloading measures resulted in the resident developing additional pressure ulcers while under the facility's care.