Failure to Follow Wound Care Orders and LALM Guidelines
Penalty
Summary
The facility failed to adhere to its own policies and procedures, as well as manufacturer guidelines, regarding the use and maintenance of Low Air Loss Mattresses (LALM) and the implementation of physician-ordered wound care interventions for three residents with pressure ulcers. Observations revealed that LALMs were not set to the correct weight settings based on resident weights, with one resident's mattress set at 250 pounds despite weighing only 121.1 pounds. Additionally, another resident's LALM was found to have a malfunctioning static mode, and alternating pressure was not observed as required. Multiple layers of linen and a disposable brief were used on top of the LALM for one resident, contrary to manufacturer instructions, potentially impeding the mattress's effectiveness. Record reviews and staff interviews indicated that physician orders for wound care were not consistently transcribed into the Physician Order Sheets (POS) and Treatment Administration Records (TAR), resulting in treatments not being administered as prescribed. For example, one resident's order for cleaning a sacral wound with Dakin's solution was omitted, and another resident did not receive the prescribed Calcium Alginate for wound care. In some cases, discontinued treatments such as Collagen were still being applied to healed wounds, and appropriate dressings like foam island or hydrocolloid were not used as ordered. Care plans for residents with pressure ulcers included interventions such as ensuring LALMs were functioning properly and set to appropriate settings, but these interventions were not consistently implemented. Staff interviews confirmed a lack of awareness or adherence to current physician orders and manufacturer guidelines. The deficiencies were identified through direct observation, interviews with wound care nurses, and review of medical records, highlighting failures in following established protocols for pressure ulcer prevention and treatment.