F0580

D

Failure to Notify Physician and Responsible Party of Discontinuation of LAL Mattress

Sylmar, California Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the attending physician and the resident’s responsible party of a significant change in treatment when a low air loss (LAL) mattress was discontinued for a resident at high risk for pressure ulcers. The resident had been admitted and later readmitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type 2 DM, and HTN. The care plan, initiated and later revised, identified the resident as at risk for unavoidable pressure ulcers related to immobility and included an intervention that the resident may have an LAL mattress for wound and skin management. An IDT wound management update documented that a lower back ulcer had resolved but still recommended an LAL mattress and off-loading. The resident’s MDS showed the resident was unable to understand and be understood and was dependent for most ADLs, and a Braden Scale assessment scored the resident at 11, indicating high risk for pressure ulcer development.

On a subsequent date, the order summary report showed an active order for an LAL mattress for wound and skin management that was discontinued with the notation that the resident’s skin was intact. There was no documentation that the physician or the responsible party were notified of this change in treatment at the time the order was discontinued. Social services documentation later recorded that a family member complained that the mattress had been removed and questioned whether there was a physician’s order to remove it. The treatment nurse told the family member that no physician order was necessary because the resident did not have wounds and that the LAL mattress was not needed. The treatment nurse also stated in interview that the LAL mattress had been removed about a week earlier based on direction from the DON to discontinue LAL mattresses for residents without pressure ulcers and that neither the physician nor the family were notified because the facility followed a protocol and there was no perceived change in condition.

During interview and concurrent record review, the DON acknowledged that, based on the Braden assessment, the resident needed the LAL mattress even without an active pressure ulcer and that an order was required both to initiate and discontinue the LAL mattress. The DON stated that if the treatment nurse did not notify the physician, there was an issue, and confirmed that this should have been considered a change in treatment requiring physician notification. The DON further stated that the family had the right to know when there is a change in treatment and that the responsible party should have been notified on the date the order was discontinued, and that failure to notify the resident representative of the change in treatment was a violation of the resident’s and representative’s right to know and make decisions. Facility policies on change in condition and support surface guidelines required prompt notification of the physician and resident representative when medical treatment is significantly altered and the use of appropriate support surfaces for individuals at risk for pressure ulcers.