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.
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 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.
A resident with Parkinson’s disease and a sacral pressure ulcer had a wound consultant recommend Dakin’s-soaked gauze, but the order lacked a specified strength and was not clarified promptly. Staff implemented 0.5% Dakin’s without documented physician clarification, and interviews confirmed the order was vague, the clarification was delayed, and the resident reported burning during wound care.
Improperly Set Specialty Mattresses: Two residents were observed on specialty mattresses that were set far above their documented weights. Both residents had intact cognition, active orders for air loss mattresses with shift monitoring, and care plans noting a history of skin impairment. An LPN stated she did not know the correct settings and believed maintenance was responsible for setup and monitoring, while the DON said nurse signatures on the TAR meant the mattresses were being monitored and set to the residents’ weights.
A facility failed to ensure specialty air mattresses were set and monitored according to resident weight and comfort for multiple residents. Surveyors observed mattresses set at incorrect weight ranges or with unclear indicator lights, while staff gave conflicting statements about whether nursing, maintenance, or hospice was responsible. Records showed orders for shift checks and nursing signatures on MARs/TARs, but staff interviews and documentation review showed the mattresses were not consistently verified as required.
A facility failed to ensure that alternating air pressure mattresses were functioning properly and set according to resident weight and physician orders for two residents with skin integrity concerns. One resident had severe cognitive impairment, malnutrition, and a history of wound care, while the other had moderately impaired cognition, malnutrition, and a stage 4 pressure ulcer. Surveyors repeatedly observed the mattress pumps set far above each resident’s recorded weight, and the DON later confirmed the incorrect settings and adjusted them during the survey.
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