Low Air Loss Mattresses Set Incorrectly for Multiple Residents: Surveyors observed several residents on specialty air mattresses that were set to weights that did not match their current body weights, including residents with pressure ulcers, malnutrition, dementia, and other serious diagnoses. An UM and LPNs acknowledged the settings were incorrect, and one resident had a mattress in place without a PO or TAR monitoring. The facility policy stated that air mattresses are to be ordered, monitored, documented, and checked every shift.
Failure to offload a resident's heels as ordered. A cognitively intact resident at risk for pressure injury had a physician order for heel booties when in bed, with placement to be checked each shift, and the care plan included heel protectors. An RN documented the device as in place on the eTAR, but during survey observation the heel booties were not on the resident and could not be found in the room; the RN acknowledged the mistake, and the UM/RN confirmed the initials meant the booties were supposed to be on the resident.
A resident with a facility-acquired Stage 3 PU, cerebral infarction, and malnutrition had an air mattress observed set at 260 despite weighing 126 pounds, and two LPNs confirmed the setting. The resident also had an IV Vancomycin order for wound infection with blank eMAR entries that were neither documented as administered nor held. The RN/UM and DON stated that blanks should not be present without proper hold documentation, and the facility policy required documentation when a medication is withheld, refused, or given at a different time.
Air Mattress Set Incorrectly for Resident With Stage IV Sacral Ulcer: A resident with quadriplegia, trach and PEG status, and an unhealed stage IV sacral ulcer was observed on a low air loss mattress pump set to 380 lbs despite a documented weight of 149 lbs. The DON stated the setting should match the resident’s weight, while an LPN said she was not sure the dial should correlate to weight and had not been trained on it. Nursing staff reported checking the mattress each shift by observation, but the pump remained set at 380 lbs during repeated observations.
Surveyors found that the facility failed to follow professional standards and internal policies for pressure ulcer prevention and treatment for two residents. One resident with dementia and a right femur fracture, weighing about 100 lbs, was observed on a low-air-loss mattress set to 220 lbs, despite a physician order for a specialty mattress and a policy requiring mattress settings to match resident weight and be verified each shift; the care plan for skin integrity risk did not list the low-air-loss mattress as an intervention. Another resident with multiple chronic conditions had a full-thickness right lower leg skin tear with physician-ordered daily and PRN wound care, but the eTAR showed no nurse signatures for completion of the ordered treatments over six consecutive days, contrary to the facility’s wound care policy requiring treatments to be completed and documented.
A resident with a sacral pressure ulcer, ventilator dependence, and total staff dependence was observed on an air mattress set at 200 pounds, then later at 300 pounds, despite a documented weight of 114.6 pounds. The record included wound care orders but no order for an air mattress. Staff stated they checked that the mattress was inflated and functioning, while the DON stated the setting should be based on the resident’s weight and checked each shift.
A resident with a Stage 3 sacral/coccyx pressure ulcer and multiple chronic conditions, including quadriplegia and DM2, had daily wound care that was not documented on the eTAR for one day. The surveyor also found that a wound care consultant recommended changing the treatment to collagen powder, but there was no contemporaneous documentation that nursing notified the physician or that the physician reviewed, accepted, or declined the recommendation, and the original Triad paste order remained in place.
Pressure ulcer treatment, documentation, and hand hygiene failures: A resident with severe cognitive impairment and facility-acquired heel and buttock pressure injuries had missing eTAR signatures for ordered wound care, no timely CP for the heel wound, and no CP for the buttock wound. During observed wound care, an LPN used a handwashing method that did not match policy, and a CNA returned room items to the treatment cart without disinfecting them. Staff confirmed the documentation gaps and improper hand hygiene process.
Air mattress settings were not matched to resident weight for multiple residents with pressure injury risk, impaired mobility, incontinence, and cognitive impairment. Surveyors observed mattresses set at incorrect weights, including settings far above or below the residents’ documented weights, and one resident had no active air mattress order even though the mattress remained in use. Staff confirmed the mattresses were intended for pressure prevention and that the setting should correspond to the resident’s weight.
Pressure ulcer care, assessment, documentation, and wound treatment failures: Surveyors found that multiple residents had pressure injuries or skin breakdown with missing or conflicting nursing notes, no formal skin risk assessment, incomplete or absent care plans for actual wounds, and no incident reports or investigations. One resident’s wound care was also observed to be performed with poor infection control, including reuse of gloves during treatment, failure to disinfect supplies and surfaces, and lack of hand hygiene/ABHS when leaving the room.
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