Incorrect LALM Setting for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to set a low air loss mattress (LALM) at the correct setting for a resident with multiple pressure ulcers, as required by the facility's policy and physician's order. The resident, who was admitted with a Stage 4 sacral pressure ulcer, five unstageable pressure ulcers, and a history of diabetes mellitus, was dependent on staff for all activities of daily living and had severe cognitive impairment. According to the resident's care plan and physician's order, the LALM was to be set based on the resident's weight, which was documented as 94 lbs. During an observation, the LALM was found set at 160 lbs, significantly higher than the resident's actual weight. Both the LVN and DON confirmed that setting the LALM above the resident's weight would make the mattress too hard, potentially worsening the resident's wounds. The facility's policy on skin integrity management required staff to implement pressure ulcer prevention measures and to provide care in accordance with physician orders, which was not followed in this instance.