Failure to Provide Timely and Monitored Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when a resident with multiple pressure ulcers did not receive necessary treatment and services consistent with professional standards of practice to promote healing. The resident had a history of pressure ulcers on the right heel, right buttock, and left heel, as well as diagnoses of type II diabetes mellitus and peripheral vascular disease. Despite weekly wound consults recommending an air mattress for additional pressure relief, there was a three-week delay in applying the recommended air mattress to the resident's bed. There was no documentation to explain this delay, and no evidence of interdisciplinary team discussions regarding the delay was provided. When the air overlay mattress was eventually placed, there was no physician's order for its use, nor was there documentation that staff were monitoring the function or settings of the mattress. Observations revealed that the air overlay mattress pump was repeatedly found turned off, the air hose was disconnected and found on the floor, and the pump was set for an incorrect weight. Additionally, the securing clip for the hose was broken, and the pump was not consistently operational until maintenance intervened. The resident's actual weight was significantly lower than the pump setting, and there was no evidence that staff were ensuring the equipment was functioning as intended. Facility policies required that residents with wounds receive care to promote healing and prevent infection, and that interventions be revised based on their effectiveness. However, the lack of timely implementation of the recommended air mattress, absence of monitoring, and failure to ensure the equipment was functioning properly led to the resident not receiving the necessary treatment and services to promote healing of pressure ulcers. The deficiency was identified through clinical record review, staff interviews, and direct observation.
Plan Of Correction
1. R 10's air mattress connector hoses were immediately replaced on 12/11/25 and set to the proper weight setting. A physician order was obtained to check the mattress for each shift for proper functioning and weight setting. 2. A facility-wide audit was conducted on 12/11/25 to identify any resident with an air mattress. Physician orders will be obtained to check functioning and settings each shift. Most recent wound consultative reports will be reviewed by the Director of Nursing for any air mattress recommendations to validate follow-through. 3. Licensed nurses will be re-educated by the Director of Nursing on checking proper functioning/settings of air mattresses and follow-through of wound consult recommendations to promote healing of pressure ulcers. Licensed Nurses will sign each shift on the treatment record validating proper functioning and settings are in place for air mattresses. Wound consult reports will be reviewed weekly during the daily interdisciplinary team meeting to validate that recommendations have supportive documentation for being addressed. 4. DON or designee will conduct weekly random direct observations of air mattresses across all 3 shifts for proper functioning, settings, and documentation for a minimum of 12 observations per week x 12 weeks. DON or Designee will conduct weekly audits of 5 residents/week x 12 weeks receiving wound consultation for supportive documentation of follow-through of recommendations. Findings of audits will be analyzed to identify/track trends or patterns and will be reported to the facility Quality Assurance/Performance Improvement Committee for review and/or recommendation.