Failure to Ensure Proper Pressure Ulcer Prevention and Equipment Use
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for three residents with existing pressure injuries or at high risk for developing them. For two residents with physician orders for low air loss mattresses, staff did not set the mattresses to the correct weight-based settings as required. One resident's mattress was set for 250 lbs instead of the actual weight of 151 lbs, and another's was set for 320 lbs instead of 148 lbs. These incorrect settings were observed on multiple occasions, and the wound nurse confirmed that proper weight-based settings are necessary for effective pressure redistribution and wound healing, as outlined in the mattress operation manual and physician orders. Additionally, a third resident, identified as high risk for pressure ulcers and with existing moisture-associated skin damage, was observed using a wheelchair cushion that was bottomed out and sunken in the middle, resulting in direct pressure on the sacral area. The cushion remained in poor condition over several days, and nursing staff acknowledged the issue but did not immediately replace it. Facility policy requires the use of pressure-reducing pads in chairs for residents at moderate to high risk, but this was not followed for the resident in question.