Failure to Provide Ordered Specialty Mattress Results in Pressure Ulcers
Penalty
Summary
A deficiency occurred when a resident with a history of pressure ulcers and multiple risk factors, including diabetes and muscle weakness, was transferred to another unit without their prescribed specialty ROHO mattress. The resident had physician orders for the specialty mattress to be in place and checked every shift, as well as a care plan identifying them as high risk for pressure injuries. Despite these orders and the facility's policy requiring all specialty mattresses to be checked and maintained, the mattress was not transferred with the resident, and staff documented its absence on several shifts. During the period when the specialty mattress was not in place, the resident developed new pressure ulcers: a stage three full-thickness wound on the left buttock and a stage two partial-thickness wound on the right buttock. Multiple staff interviews and documentation confirmed that the mattress was not present for several days following the transfer, and that nursing staff were aware of the absence but did not ensure the mattress was moved or that alternative interventions were implemented. The facility's own investigation and wound care assessments attributed the development of these wounds to the lack of the specialty mattress during this time. Interviews with clinical staff, including the wound care nurse, physician assistant, and medical director, confirmed that the absence of the specialty mattress directly contributed to the resident's skin breakdown. The medical director specifically stated that the pressure ulcers were avoidable and that the resident's condition had been stable prior to the transfer. Documentation also showed inconsistencies in the treatment administration record, with some staff marking the mattress as 'administered' when it was not present, further indicating lapses in care and documentation.