Failure to Provide Specialized Mattresses for Residents with Pressure Injuries
Penalty
Summary
The facility failed to provide specialized mattresses to two residents who had significant pressure injuries to their sacrum, despite physician orders and documented needs for pressure redistribution devices. One resident was admitted with a stage 4 pressure ulcer and had repeated documentation in progress notes indicating the need for a pressure redistributing mattress, but was placed on a regular mattress throughout their stay. The Assistant Director of Nursing (ADON) confirmed that the resident should have been on a specialized air mattress, such as a low air loss mattress (LALM), and acknowledged that this intervention was not included in the resident's care plan. Another resident with a pressure injury to the tailbone was also observed on a regular mattress, despite a physician's order for a LALM. The ADON stated that the facility was out of specialized mattresses and could not find documentation that the physician was notified about the unavailability of the ordered mattress. The facility's policies require the use of appropriate pressure-redistributing support surfaces for residents with pressure injuries and mandate that such interventions be documented in the care plan. These failures were identified through observation, interviews, and record reviews.