Failure to Specify and Document Pressure Mattress Settings for Resident at Risk for Pressure Injuries
Penalty
Summary
A deficiency was identified when the facility failed to ensure a physician's order specified the settings for a pressure redistribution air mattress for a resident with multiple diagnoses, including dementia, weakness, and risk for pressure injuries. The resident was dependent on staff for bed mobility and transfers, had severely impaired cognition, and was at risk for pressure ulcers. Physician orders directed staff to check the function of the air mattress every shift and evaluate for bottoming out, but did not specify the required mattress settings based on the resident's weight. During observation, the air mattress was set above 160 pounds, despite the resident's recorded weight being 122.2 pounds, and there were no markers to identify the exact setting. Staff estimated the dial position rather than using a precise setting, and there was no documentation that licensed staff were checking the settings as required. Interviews with facility leadership confirmed that the air mattress settings should be based on the resident's weight and that inaccurate settings could increase the risk for skin breakdown. The facility's policy required support surfaces to be used according to physician orders and checked each shift for proper functioning. However, the lack of specific orders for mattress settings and absence of documentation verifying checks contributed to the deficiency. The resident subsequently developed two new unstageable wounds to both feet, as documented by a wound care specialist.