Failure to Provide Proper Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for five residents, as evidenced by multiple lapses in following established policies and care plan interventions. Staff did not ensure that low air loss mattress (LALM) settings matched residents' weights, did not maintain the cleanliness of LALM devices, and allowed excessive layers of linen beneath residents, contrary to facility policy. In one instance, a resident with an unstageable pressure injury to the sacrum was found lying on a LALM with five layers of linen, a soiled and partially uncovered wound dressing, and a visibly dirty mattress surface. Staff interviewed were unsure of the correct LALM settings and could not explain the significance of the settings in use. Additional deficiencies included the failure to provide pressure-reducing cushions for residents at risk of pressure ulcers while seated in wheelchairs, as required by their care plans and physician orders. Several residents were observed without the necessary gel chair cushions, and their LALM settings were not adjusted to reflect their current weights, as documented in their records. Staff acknowledged that the LALM settings should correspond to the resident's weight but were not consistently aware of or following this requirement. The facility's own policies specify the use of minimal linen layers on LALMs, prompt identification and treatment of skin breakdown, and the use of pressure redistribution devices for at-risk residents. Despite these policies, observations and interviews revealed that staff were not consistently implementing these interventions, resulting in residents being left without appropriate pressure ulcer prevention measures, incorrect mattress settings, and inadequate wound care.