F0656

D

Failure to Include Ordered Pressure-Relieving Mattress in Comprehensive Care Plan

Lubbock, Texas Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and revise a comprehensive care plan to include a physician-ordered pressure-relieving mattress for a resident with a significant pressure ulcer. The resident, an older male with quadriplegia and severely impaired cognition, was admitted with a coccyx pressure ulcer that was present on admission and greater than three months in duration. The comprehensive MDS identified the resident as at risk for pressure ulcers, with a triggered CAA for pressure ulcers that should have been care planned, and documented the use of a pressure-reducing device for the bed. Physician orders included a pressure-reducing mattress to the bed with a start date in November and detailed wound care orders for an unstageable coccyx pressure ulcer. Despite these orders and the resident’s high-risk condition, the written care plan did not include the low-pressure airflow mattress as an intervention.

Record review showed that the resident’s care plan, last revised in early January, contained a focus on wound management with goals for wound improvement and freedom from infection, and interventions such as administering antibiotics as prescribed, notifying the provider if there was no improvement, and providing wound care per treatment orders. Another care plan focus addressed the resident’s resistance to repositioning due to anxiety, with interventions including education about noncompliance and praise for appropriate behavior. However, the care plan lacked any reference to the ordered pressure-relieving mattress, did not provide clear guidance for staff on implementation or monitoring of the mattress, and did not outline expectations for pressure injury management related to the specialized bed. Progress notes over several months documented the presence and progression of the coccyx wound, including staging changes from Stage 2 to unstageable, wound measurements, infection, antibiotic use, and additional care such as turning/repositioning and pressure-reducing devices, but did not include progress notes specifically addressing the pressure-relieving mattress.

Interviews and observations further demonstrated gaps in care planning and staff knowledge related to the low-pressure airflow mattress. On observation, the resident was seen lying on a low-pressure airflow mattress with the static button turned on, and the resident and a family representative reported repeated concerns that the bed was not properly inflated, with staff appearing unsure how to manage or check the bed. Multiple CNAs and an agency nurse reported they had not received instruction or individualized training on low-pressure airflow mattresses and were unclear about who was responsible for checking them. The MDS Coordinator, ADONs, and DON all stated that the low-pressure airflow mattress should have been care planned as an intervention, and acknowledged that it was not included in the resident’s care plan. Leadership interviews revealed confusion and inconsistency about who was responsible for ensuring such interventions were entered into care plans, especially after the facility no longer had a designated wound care nurse, and there was no specific policy for low-pressure airflow mattresses. The DON stated that the care plan should have reflected the implementation of the low-pressure airflow bed at admission and acknowledged that the omission could result in worsening wounds or increased infection, confirming that the ordered pressure-relieving mattress was not incorporated into the comprehensive care plan as required.

The facility’s own staff described the care plan as the primary guide for all staff to know residents’ active issues, conditions, and required interventions, and recognized that missing interventions could place residents at risk for decline. Despite this, the system described for monitoring and updating care plans—baseline care plans within 48 hours, discussion in morning meetings, and quarterly or change-in-condition reviews—did not result in the inclusion of the low-pressure airflow mattress for this resident. The MDS Coordinator indicated that, historically, the wound care nurse would have ensured wound-related interventions were added to care plans, but after that role was vacated, no clear reassignment of those duties occurred. The DON and administrative staff acknowledged overall responsibility for ensuring interventions were included in care plans, yet they were unaware that this resident’s mattress intervention was missing until it was identified during the survey. This combination of incomplete care planning, lack of documented guidance on the mattress, and staff uncertainty about mattress operation and monitoring led to the cited deficiency for failure to develop and revise a comprehensive care plan consistent with the resident’s assessed needs and physician orders.