Failure to Include LAL Mattress in Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop and implement a care plan addressing the use of a low air loss (LAL) mattress for a resident with a history of pressure injuries and multiple complex diagnoses, including palliative care, senile degeneration of the brain, vascular dementia, and stage 3 pressure ulcers on the sacral region and left buttock. The resident had an active physician order for a LAL mattress for prophylactic skin management, which was initiated to prevent further skin breakdown and manage existing pressure injuries. Despite the presence of the LAL mattress in the resident's room and its documented use, review of the resident's care plans revealed that this intervention was not included. Interviews with nursing staff and the DON confirmed that the care plan did not reflect the use of the LAL mattress, even though it was a significant intervention for the resident's skin integrity. Staff acknowledged that care plans serve as essential communication tools and guides for providing individualized, person-centered care, and that all physician orders and interventions should be documented in the care plan. The facility's policies and procedures required the development of comprehensive, individualized care plans with measurable objectives and timetables to meet each resident's needs, including interventions for skin integrity management. The DON confirmed that the facility's policy was not followed in this case, as the care plan did not include the LAL mattress intervention, which was necessary for the resident's ongoing skin management and prevention of further pressure injuries.