Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide low air loss mattresses for two residents with Stage 4 sacral pressure ulcers, despite physician orders and care plans specifying this intervention. One resident was admitted with a Stage 4 sacral pressure ulcer and deep tissue damage to the right heel, with both the wound physician's plan of care and the resident's care plan indicating the need for a low air loss mattress. However, during observation, the resident was found in bed without the required mattress and confirmed not having a special mattress. The wound care nurse also verified that the resident did not have a low air loss mattress and stated that all residents with pressure wounds should have one. A second resident, also admitted with a Stage 4 sacral pressure ulcer, was observed in her room without a low air loss mattress. During the survey, maintenance staff entered to replace her standard mattress with a low air loss mattress, and the resident confirmed she was receiving the new mattress as recommended by the wound care doctor. The facility's policy requires evidence-based interventions, including appropriate pressure-redistributing support surfaces, for all residents with pressure injuries. Despite this policy and physician recommendations, the required mattresses were not provided to these residents.