Failure to Provide Recommended Pressure-Relieving Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide or replace a pressure-relieving Dolphin Mattress for a resident with a history of chronic Stage 4 pressure injuries and osteomyelitis, despite multiple recommendations from a wound care consultant. The resident, who required assistance with bed mobility and transfers, had a documented need for a Dolphin Mattress to prevent further skin breakdown and assist in wound healing. The wound care consultant repeatedly communicated the necessity of this specific mattress to the nursing staff, noting that the replacement mattress in use was not sufficient for offloading pressure. Despite these recommendations, the facility replaced the broken Dolphin Mattress with a MATT-EASY AIR mattress, which operates by alternating air rather than fluid. Staff interviews confirmed that the wound care recommendations were received and acknowledged, but the Dolphin Mattress was never replaced. The Director of Nursing indicated that the previous administration was aware of the recommendation but opted not to replace the mattress, possibly due to cost concerns. At the time of observation, the resident continued to use the non-recommended mattress, contrary to the wound care consultant's orders.