Incorrect LALM Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs) were set correctly according to residents' weights for three residents who were at risk for or had a history of pressure ulcers. For one resident with dementia, muscle wasting, and moderate cognitive impairment, the LALM was set at 350 lbs, while the resident's actual weight was 119 lbs. The physician's order required the LALM to be checked for proper placement and function every shift, but this was not done, as confirmed by the nurse and the Director of Nursing (DON). Another resident with severe cognitive impairment and muscle wasting had an LALM set at 50 lbs, despite a sticker on the device indicating it should be set between 100-150 lbs for the resident's actual weight of 128 lbs. The nurse confirmed the setting was incorrect and that the LALM was being used for pressure ulcer prevention. The DON acknowledged that the LALM should be set according to the resident's weight and that failure to do so could negatively affect the resident's skin. A third resident with dementia, difficulty walking, and epilepsy had an LALM set at 320, while the resident's weight was 108 lbs and a sticker on the device indicated the correct setting should be 100. Both the registered nurse and the treatment nurse confirmed the setting was incorrect and explained that improper settings could cause discomfort and increase the risk of pressure injury. Facility policy and the manufacturer's guide both required LALMs to be set according to the resident's weight, and staff interviews confirmed that this was not consistently done.