Failure to Implement Ordered Pressure-Relieving Interventions for At-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure-relieving interventions for residents identified as at risk for pressure injuries. For one resident (R5), the Medication Review Report dated 8/26/25 showed an order for an air mattress to be on at all times. Observations on 8/25/25 at 2:06 PM and on 8/26/25 at 1:42 PM found the resident in bed with the air mattress pump hanging at the foot of the bed, with the lights off and the pump unplugged on both occasions. On 8/27/25 at 9:01 AM, an LPN (V13) confirmed that an air mattress pump is a pressure-relieving intervention. R5’s Braden Scale dated 8/18/25 indicated the resident was at risk for pressure injuries, and the care plan revised 8/19/25 documented potential for skin impairment with an air mattress listed as an intervention. The deficiency also includes failure to apply ordered protective boots for another resident (R30) at risk for pressure injuries. On 8/25/25 at 1:35 PM, two CNAs (V10 and V11) transferred R30 to bed with a mechanical lift and provided incontinence care, then positioned the resident’s feet on the mattress without applying the protective boots. A bright-colored sign above the bed displayed a turning schedule and directed that cradle boots be on at all times when the resident was in bed. On 8/26/25 at 12:33 PM, an RN (V8) stated that R30 is at risk for pressure, dependent on staff for care, and should have protective boots applied when in bed. R30’s current care plan documented potential impairment to skin integrity related to fragile skin, with interventions including an air mattress, wheelchair cushion, and protective boots while in bed. The facility’s Pressure Injury Prevention and Management Policy states that interventions will be implemented for all residents assessed and considered at risk.
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