Failure to Provide Required Pressure-Relieving Cushion for Resident with Pressure Ulcers
Penalty
Summary
A resident with a history of pressure ulcers, diabetes, heart failure, and debility was admitted with multiple pressure injuries, including a stage II, a stage III, and an unstageable deep tissue injury. Physician orders and the care plan required the use of a gel cushion in the resident's wheelchair to reduce pressure and prevent further skin breakdown. Documentation in the Treatment Administration Record (TAR) indicated that the gel cushion was checked daily by the wound care nurse, and the Kardex instructed nursing assistants to provide the cushion. However, during multiple observations and interviews over several days, the resident was repeatedly found sitting in her wheelchair without the required cushion, both in her room and during activities. The resident reported discomfort and pain when sitting for extended periods and was unable to participate fully in social activities due to this pain. Staff interviews revealed inconsistent awareness and follow-through regarding the presence of the cushion. The wound care nurse acknowledged signing off on the TAR without confirming the cushion's presence, and nursing assistants were unsure when the cushion was last seen in use. The Director of Nursing stated that all wheelchair users should have a cushion and that staff had been in-serviced to validate interventions before documenting them. Despite these protocols, the required pressure-relieving cushion was not consistently provided, resulting in the resident experiencing discomfort and limiting her participation in activities.