Failure to Ensure Proper Functioning of Low Air Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors for pressure ulcers, including peripheral vascular disease, anemia, edema, and limited mobility, was not provided with a properly functioning low air loss mattress as ordered. The resident's care plan and physician orders specified the use of a low air loss mattress with perimeters, set according to weight and alternating pressure, with functionality checks required every shift. Despite these orders, observations on two consecutive days revealed that the mattress panel was blinking red, indicating low pressure, and the alarm had been muted. Staff had documented on the treatment administration record that the mattress was functioning, but direct observation contradicted this documentation. Multiple staff, including a registered nurse, wound nurse, and wound nurse practitioner, were either unaware of the malfunction or did not notice the low-pressure indicator and muted alarm during their assessments and rounds. The mattress remained in use while malfunctioning, and the issue was not identified or addressed until it was brought to the attention of staff during the survey. The resident was observed lying in bed on the malfunctioning mattress, and staff were unable to confirm whether all air cells were properly inflated due to the mattress cover and the resident being in bed. The facility's operational manual for the mattress clearly states that a low-pressure indicator and alarm are designed to alert staff to malfunctions, and the facility's policy requires monitoring and revising interventions as appropriate. However, the required checks and responses to the alarm were not performed, resulting in the resident not receiving care consistent with professional standards of practice to prevent pressure ulcers.
Plan Of Correction
The facility will continue to ensure low air loss mattresses are functioning properly. Resident #240 continues to reside at the facility. On 3/25/2025, the Administrator removed the mattress and pump and replaced it with a functioning mattress and pump. Resident #240's skin was assessed and noted with no new identified areas. RN #60 was reeducated by the facility wound nurse on properly monitoring the low air loss mattresses for proper functioning. An initial audit of current residents with low air loss mattresses was conducted for function on 3/27/2025 by the DON. No negative findings were noted at the time of the audit. By 4/17/2025, the DON and/or designee will reeducate the licensed nurses and direct care staff on ensuring proper function of low air loss mattresses and how to troubleshoot alarms to pumps per manufacturer guidelines. Weekly, for 2 weeks, or as directed by the QA committee, the facility wound nurse and/or designee will randomly audit 5 residents, ensuring the low air loss mattress is set properly, functioning, and not alarming. Negative findings will be immediately corrected by assessing the mattress and resident and replacing the mattress as appropriate. Negative findings will also be reported to the QA committee for review. The facility Administrator will ensure the completion of the weekly audits. The DON is responsible for the ongoing compliance. F 0686