Failure to Prevent Pressure Ulcers and Ensure Proper Air Mattress Settings
Penalty
Summary
The facility failed to prevent an avoidable pressure wound in a resident identified as high risk for skin breakdown and dependent on staff for turning and repositioning. The resident's Braden scale assessment indicated a high risk for pressure sores, with very limited mobility and a need for moderate to maximum assistance. Despite this, the resident developed a facility-acquired stage 3 pressure wound on the left ear, which was observed by nursing staff and confirmed by the wound physician. Staff interviews and observations revealed that the resident was not turned and repositioned as required, and the wound was attributed to prolonged pressure from lying on a pillow with a plastic covering that created folds, as well as possible contact with a call light cord. The Director of Nursing confirmed that the wound resulted from staff not turning and repositioning the resident as needed. Additionally, the facility failed to ensure that air mattress pumps were set according to manufacturer recommendations based on residents' weights. Observations showed that two residents at risk for pressure ulcers had their air mattress pumps set significantly higher than their actual weights. For example, one resident weighing 117 pounds had the mattress set at 200 pounds, and another weighing 63.6 pounds had the mattress set at 280 pounds. The wound nurse acknowledged that incorrect mattress settings would not provide the intended benefit for pressure ulcer prevention. Maintenance staff reported that there was no policy in place for setting air mattress pumps, and that they relied on verbal instructions from nursing staff. The lack of proper mattress settings and failure to turn and reposition high-risk residents contributed to the development and risk of pressure ulcers among the affected residents.