Failure to Provide Appropriate Pressure Ulcer Treatment and Mattress Use
Penalty
Summary
A Stage 3 pressure ulcer was present upon admission for a resident with diagnoses including hypertensive chronic kidney disease and peripheral vascular disease. The wound, located on the coccyx, was documented as having serosanguineous drainage and surrounding discoloration. The care plan included interventions such as a pressure reducing mattress and treatment per physician order. However, the initial physician order was for a protective cream to be applied after incontinence episodes, which was not appropriate for a deep wound as indicated by the product's warning label. No dressing was used to cover the pressure ulcer until several days after admission, despite the wound's severity. Additionally, during wound care observation, the resident was found on a low air loss mattress with a fitted sheet, a cloth bed pad, and an incontinence brief, resulting in multiple layers between the resident and the mattress. The mattress user manual specifically recommended avoiding multiple layers of linens or underpads to promote healing of pressure injuries. Staff interviews confirmed that the protective cream was used as a routine order and that multiple layers were present, contrary to manufacturer guidelines. These actions and inactions led to the deficiency cited in the report.