Failure to Set Low Air-Loss Mattress per Physician Order for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that a resident with significant pressure injury risk received pressure ulcer care consistent with professional standards and physician orders. The resident was admitted with an unstageable pressure ulcer on the right upper back and later had a documented Stage 4 pressure ulcer on the right back. The resident’s care plan, revised in early November, identified the resident as being at risk for further skin breakdown and delayed wound healing and included use of a low air-loss mattress (LALM) as an intervention for pressure injury management. The resident’s MDS showed severely impaired cognitive skills for daily decision-making, and the resident had multiple medical conditions including cerebral infarction and a gastrostomy. During observation and interview, an LVN reported that the LALM was programmed for a weight range of 300–350 lbs, even though the resident’s documented weight was 161 lbs. Review of the physician’s order showed that the LALM was to be calibrated to 180 lbs for pressure injury management, and the LVN acknowledged that the mattress should have been set to 180 lbs in accordance with that order. The DON confirmed that the physician’s order for the LALM setting was not followed and that the mattress setting was not adjusted based on the resident’s weight and the physician’s order. Facility policies on pressure injury prevention and mattresses indicated that pressure-redistributing devices and appropriate mattresses were to be used to provide pressure reduction and evenly distribute body weight, but the LALM settings for this resident were not aligned with those requirements.
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