Failure to Provide Appropriate Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide necessary care and services related to pressure injuries for three residents reviewed for wound management. For one resident with a Stage 4 sacrococcyx pressure injury, the wound increased in size and necrotic tissue, but there was no documentation that the Wound Care Physician was informed of these changes. The wound assessments showed a progression from partial granulation and necrotic tissue to 100% necrotic tissue and an increase in wound size over several weeks. Interviews with nursing staff confirmed that the physician should have been notified and that this notification should have been documented, but this did not occur. For two other residents, the facility failed to ensure that the Low Air Loss (LAL) mattress settings were consistent with each resident's current weight. One resident, weighing 141 pounds, was observed with the LAL mattress set for a weight range of 165 to 250 pounds, which did not match the resident's actual weight. Another resident, weighing 119 pounds, was observed with the LAL mattress set at 300 pounds. Staff interviews confirmed that the mattress settings should correspond to the resident's weight and that incorrect settings could affect wound healing. The responsible nurses did not check or adjust the mattress settings during wound care. Facility policies required individualized care plans, regular wound assessments, and appropriate use of pressure-redistributing support surfaces. Documentation and staff interviews revealed that these policies were not consistently followed, as evidenced by the lack of physician notification for wound deterioration and improper mattress settings for residents at risk for or with existing pressure injuries.