F0686

G

Failure to Monitor and Maintain Pressure-Relieving Mattress Leads to Worsening Stage IV Ulcer and New DTIs

Fremont, Ohio Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and monitor pressure-relieving interventions, including a low air loss/alternating air mattress, for a bedbound resident with a pre-existing stage IV pressure ulcer and multiple comorbidities. The resident had diagnoses including multiple sclerosis, sepsis, severe protein-calorie malnutrition, chronic respiratory failure, Crohn’s disease, colostomy, neuromuscular bladder dysfunction, and a long-standing stage IV left buttock pressure ulcer. A care plan and physician orders called for use of a low air loss mattress, turning and repositioning at least every two hours, heel off-loading, and monitoring of wound status and mattress function. However, on readmission from the hospital, the nursing assessment documented only an area of skin breakdown to the buttocks without describing or measuring the wound, and there was no documentation of what pressure-relieving surface was in use or any assessment of the low air loss mattress for proper fit or operation.

Between the resident’s readmission and several days afterward, the medical record lacked documentation that the alternating air mattress function was checked each shift, despite a prior order to do so. There were also gaps in documentation of wound treatments: no wound treatment applications, including the hospital-ordered TRIAD barrier/autolytic debridement, were recorded from readmission until a new dressing order was obtained days later. Turning and repositioning documentation showed long intervals without recorded repositioning, particularly from the time of readmission until early the next morning, and then only sporadic repositioning entries over subsequent days. The record did not contain any documentation that the resident refused repositioning during this period, nor any documentation of off-loading or side-to-side positioning consistent with the care plan and wound specialist recommendations.

On one date, nursing notes recorded that staff discussed transferring the resident to a wheelchair so the bed mattress could be worked on, and the resident refused transfer by mechanical lift, stating she would remain in bed until family could transfer her. After this refusal, the record contained no further documentation of attempts to replace or repair the faulty mattress, no re-approach to address the refusal, and no additional interventions to reduce pressure. When surveyors observed the resident, she was lying on her back on a low air loss mattress with an active visual alarm indicating alternate failure and a muted audible alarm. Her feet extended beyond the end of the mattress, with pillows filling an 18-inch gap between the mattress and footboard, and she reported sitting on the metal bed frame. An LPN caring for the resident was unaware the mattress was malfunctioning, did not know how to verify proper operation beyond checking the mattress sides, and confirmed the resident was sitting with direct pressure on the metal frame. Subsequent wound evaluation with the wound specialist showed the original stage IV left buttock ulcer had enlarged and three additional unstageable deep tissue injuries on the back and buttock had developed, which the surveyors attributed to the lack of appropriate pressure-relieving interventions and monitoring.

Facility leadership later confirmed that wound measurements and descriptions were not obtained at readmission and were not documented until the wound specialist’s evaluation several days later. They also verified that, following the resident’s refusal to be transferred for mattress work, the medical record lacked evidence of re-approach, assessment of the cause of refusal, or implementation of additional measures to promote skin integrity. The facility’s own pressure ulcer/skin breakdown protocol required examination of newly admitted residents’ skin, physician orders for appropriate pressure reduction surfaces, and ongoing review of whether current approaches remained pertinent to the resident’s condition. The survey findings concluded that these required assessments and interventions were not carried out or documented, resulting in deterioration of the existing stage IV ulcer and the development of three in-house acquired unstageable deep tissue injuries.