Failure to Set Low Air-Loss Mattress According to Resident Weight
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident at high risk for pressure ulcers received care consistent with professional standards of practice. The resident, who had diagnoses including acute kidney failure, benign prostatic hyperplasia, and anemia, was assessed as having moderately impaired cognitive skills and required maximal assistance for mobility. The resident's care plan and physician orders specified the use of a low air-loss mattress (LALM) for wound care and management, with the mattress setting to be adjusted according to the resident's weight. The resident's most recent documented weight was 116 pounds, and the LALM was supposed to be set at 120 lbs as indicated by a label on the machine. However, during observation, the LALM was found set at 200 lbs, which did not correspond to the resident's actual weight. Both nursing staff and the Director of Nursing confirmed that the mattress should have been set based on the resident's weight and acknowledged that the incorrect setting was not in accordance with the care plan, physician orders, and manufacturer guidelines. This failure to maintain the correct LALM setting placed the resident at risk for the development of pressure ulcers, as the mattress was not providing the intended pressure relief.