Failure to Implement Pressure Ulcer Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain appropriate pressure ulcer prevention interventions for residents identified as at risk for pressure ulcers. For one resident, the Braden Scale indicated risk, and physician orders required heel protectors on both feet while in bed. However, observations showed the resident only had a heel protector on the left foot and was placed on an air mattress with a fitted sheet, which is not recommended as it can interfere with the mattress's function. The air mattress was also set to 'firm, normal pressure' rather than being adjusted to the resident's weight as required. The care plan for this resident included repositioning every two hours, use of pillows, heel protectors, and a specialty mattress, but these interventions were not consistently implemented as observed by surveyors. For another resident at risk for pressure ulcers, physician orders specified the use of a pressure reduction mattress. Observations revealed the resident was on an air mattress with a fitted sheet and the mattress was set to the maximum weight setting, which did not correspond to the resident's actual weight. Staff interviews indicated a lack of understanding regarding proper mattress settings and sheet usage, with some staff believing fitted sheets were acceptable and that mattress settings did not need adjustment. The care plan for this resident included use of a pressure-reducing mattress and wheelchair cushion, but the interventions were not properly individualized or implemented according to the resident's needs and manufacturer guidelines.