Failure to Ensure Proper Pressure Ulcer Prevention and Mattress Settings
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer prevention and care for a resident with significant risk factors and existing pressure injuries. The resident, who had diagnoses including diabetes mellitus, dementia, and was dependent on staff for bathing and toileting, was documented as having one Stage 3 and two unstageable pressure wounds. The care plan lacked specific interventions for pressure injuries on the heels and coccyx, and did not provide staff direction for monitoring the low air loss (LAL) mattress. Physician orders required heel protectors to be used every shift and specific wound care regimens, but these were not consistently implemented. Observations revealed that the resident did not have heel boots applied and her heels were not consistently offloaded, despite orders and care plan requirements. The LAL mattress was set at 180 pounds, which did not match the resident's documented weight of 121.2 pounds, and there was no documentation or direction for staff to monitor or adjust the mattress settings. Interviews with staff indicated confusion about responsibility for applying heel protectors and monitoring the LAL mattress, and delays in obtaining necessary equipment such as heel boots. The facility's policy required individualized care plans and collaboration among care team members, but these measures were not fully implemented for this resident.