Failure to Provide Ordered Low-Air-Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident, who was at high risk for developing pressure ulcers due to generalized muscle weakness and severe cognitive impairment, was not provided with a low-air-loss mattress (LALM) as ordered by their physician. The resident required supervision or assistance for bed mobility and had an active physician order for a LALM to help prevent skin breakdown, particularly around the tailbone. During an observation, it was noted that the resident did not have a LALM in their current room, while an unoccupied bed in the resident's previous room had the LALM assigned to them. Interviews with a Licensed Vocational Nurse (LVN) confirmed that the LALM was intended for the resident and that the omission occurred when the resident was moved to a new room and the mattress was not transferred as required. The LVN acknowledged that the physician's order for the LALM was still active and that the resident should have had the mattress in place. The facility's job description for LVNs indicated that staff are responsible for following physician orders and providing individualized care, which was not done in this instance.