Failure to Maintain Required Pressure-Relieving Mattress for Resident With Stage IV Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement required pressure ulcer prevention and treatment interventions for a resident with a known Stage IV pressure ulcer to the right medial buttocks. The resident had multiple diagnoses including sequelae of cerebral infarction, vascular dementia, muscle weakness, and a documented Stage IV pressure ulcer, and was assessed as severely cognitively impaired, totally dependent for all ADLs, and always incontinent of bowel and bladder. The MDS and care plan identified the resident as at high risk for skin breakdown, with a Braden score of 12, and the care plan called for monitoring factors that could lead to skin alterations and following facility policies and protocols for prevention and treatment of skin breakdown, including evaluation and treatment by a wound physician. The facility’s written Preventative Skin Care policy required special mattresses and/or chair cushions for any resident identified as high risk for skin breakdown. The wound log documented that the resident’s right medial buttock wound, categorized as end-stage skin failure, had an air loss mattress listed as preventative equipment. However, surveyor observations on two separate dates showed that the resident’s bed had a standard mattress in place while the resident had a Stage IV buttock wound and was at high risk for further breakdown. Staff interviews revealed uncertainty about whether the resident had been on an air loss mattress prior to a room change, and the business office records showed the last room move occurred several months earlier. The DON confirmed the resident had been on an air loss mattress before the room change and acknowledged not knowing why the air loss mattress was not moved with the resident, despite believing the resident still needed it. Wound measurements documented by the wound physician over multiple weeks showed ongoing depth and changes in the wound dimensions, and the wound physician stated that he initially categorized the wound as end-of-life and did not change that category, although he acknowledged it should be classified as a Stage IV pressure ulcer. The wound physician, the regional clinical director, and the medical director each stated that a resident with a Stage IV buttock wound should be on an air loss mattress and that lack of such a mattress could contribute to deterioration or impaired healing of the wound. During a wound treatment observation, an LPN measured the wound at a greater depth than previously recorded. The facility’s failure to ensure that the resident remained on an air loss mattress in accordance with the care plan, policy, and clinical expectations led to the worsening of the resident’s Stage IV pressure ulcer to the buttocks.
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