Failure to Ensure Proper Functioning and Settings of Pressure-Relieving Mattresses
Penalty
Summary
The facility failed to provide necessary treatment and services to minimize the risk of development of pressure injuries for three residents by not ensuring the proper functioning and correct settings of low air loss mattresses (LALMs) as ordered by physicians. For one resident with a history of cerebral infarction and contractures, the LALM was observed to be leaking air and held together with tape, making a loud hissing noise. A nurse confirmed the mattress was not functioning properly, which could prevent adequate pressure relief as required by the resident's care plan and physician orders. Another resident, admitted with an ulcer and open wound of the left lower leg, had a physician order for the LALM to be set at 120 lbs., while the resident's actual weight was 103.5 lbs. However, the LALM was observed to be set at 355 lbs., significantly higher than both the resident's weight and the ordered setting. A registered nurse confirmed that this incorrect setting could add pressure to the resident's back, potentially worsening their skin condition, and the DON stated that such a setting would prevent proper healing. A third resident, with diagnoses including COPD, gastrotomy, and dysphagia, was ordered a LALM with a Level 2 setting for wound prevention, which the DON clarified was intended for residents weighing 120 lbs. The resident's current weight was 82.3 lbs., indicating a mismatch between the mattress setting and the resident's needs. The facility's policy required continuous monitoring and adjustment of interventions to prevent pressure ulcers, but these actions were not consistently implemented for the residents involved.