F0686

D

Failure to Maintain LAL Mattress Function and Absence of Skin Integrity Care Plan Leading to Pressure Injury Worsening

Stockton, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and care for two residents. For the first resident, who had diabetes, muscle weakness, musculoskeletal symptoms, moderate cognitive impairment, and documented MASD on bilateral buttocks, the care plan and orders required use of a low air loss (LAL) mattress and specific buttocks skin care with normal saline and calmoseptine every shift. During a planned power shutoff in the resident’s room while maintenance worked in an adjacent room, the resident’s oxygen concentrator was switched to an oxygen tank, and the resident reported to a licensed nurse that her LAL mattress was deflating. The nurse responded that the power would be off for 15–20 minutes and did not indicate any alternative plan to keep the LAL mattress functioning. Another nurse later stated the LAL mattress should have been plugged into an emergency outlet before the power was turned off and told the resident it would be plugged into an emergency outlet.

In follow-up interviews, the first nurse stated that maintenance had informed her about the power shutoff but she did not know the protocol for using emergency extension cords to keep the LAL mattress operating. The Director of Staff Development confirmed that the orientation checklist for that nurse did not include training on the use of emergency extension cords and emergency outlets to maintain electrical equipment during power shutoffs. The Director of Nursing stated she would have expected the nurse to ask other nurses for assistance and acknowledged that a deflated LAL mattress could be uncomfortable and potentially a reason for skin breakdowns. The facility’s user manual for the LAL mattress system described its purpose as helping reduce the incidence of pressure ulcers, and the facility’s Pressure Injury Prevention Guidelines policy required prevention devices to be used in accordance with manufacturer recommendations.

For the second resident, who also had diabetes, muscle weakness, musculoskeletal symptoms, and moderate cognitive impairment, there was a concern reported by a complainant that the resident experienced a burning sensation around the buttocks. The resident later stated his bottom was hurting. Physician orders and the Treatment Administration Record showed that the coccyx area was to be washed with soap and warm water, patted dry, and calmoseptine applied every shift. A CNA reported that the resident had skin issues on the buttocks and around the anal region, with a small peeled area of skin, and stated she repositioned the resident every two hours and kept him clean and dry. A licensed nurse reported that on the previous day she had observed only skin redness with no open area on the buttocks and coccyx, and that preventive measures included keeping the resident clean and dry, reporting skin changes, and rotating his position every two hours in bed.

On a subsequent observation with the same nurse, the resident was found to have an area on the coccyx where the outer skin had come off, now an open wound measuring approximately 0.3 cm by 0.4 cm with slight drainage. The nurse stated that the area had been smaller and not open the day before and that it was now bigger and open, and she acknowledged the resident might not have been turned and repositioned as frequently as required. Review of the resident’s care plan documentation showed there was no care plan addressing his high risk for skin breakdown, and no documented interventions to prevent development or worsening of pressure ulcers. The nurse confirmed there was no skin integrity care plan and stated there should be one to guide staff, and that without a skin care plan there would be no interventions for staff to follow, which could increase the occurrence or worsening of pressure injuries. The Administrator also stated that residents at high risk for skin breakdown should have a care plan to help prevent further skin issues that could lead to infection and a decline in general health. The facility’s Pressure Injury Prevention Guidelines and Comprehensive Care Plans policies required evidence-based interventions for at-risk residents to be documented in the care plan and used to meet resident needs.