F0686

D

Failure to Implement Ordered Pressure-Reducing Seat Cushion for High-Risk Resident

Port Allen, Louisiana Survey Completed on 03-18-2026

Penalty

Fine: $15,940

Summary

A resident with chronic combined systolic and diastolic congestive heart failure, type 2 diabetes mellitus with circulatory complications, morbid obesity due to excess calories, and generalized muscle weakness was admitted with significant risk factors for pressure ulcer development. The resident’s quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment, dependence on staff for chair/bed-to-chair transfers, and a need for a pressure-reducing device for the wheelchair. Physician orders, in place since 07/23/2025, directed use of a pressure-reducing seat cushion every shift, and the care plan documented an intervention for a pressure-reducing seat cushion due to the resident’s obesity, diabetes, occasional incontinence, impaired mobility, and wheelchair use.

On the survey date, observations at 8:13 a.m. and 11:10 a.m. found the resident seated in a wheelchair without a pressure-reducing seat cushion. The resident could not be interviewed due to cognitive status. A CNA reported that the resident required two-person total assistance with transfers and incontinent care, was at risk for pressure ulcers, and had been out of bed in the wheelchair at the start of her shift; she confirmed there was no pressure-relieving cushion in the wheelchair or in the room. An LPN likewise confirmed the resident was at risk for pressure ulcer development, had a physician order for a pressure-reducing seat cushion when in the wheelchair, and that no cushion was present in the wheelchair or room when she assisted with transferring the resident back to bed. The DON reviewed the physician orders and confirmed that a pressure-reducing seat cushion should have been used any time the resident was out of bed in the wheelchair.