Failure to Set Low Air-Loss Mattress Correctly for Pressure Ulcer Prevention
Penalty
Summary
A resident with diagnoses including pneumonia, osteoarthritis, and dementia was admitted to the facility and assessed as being at moderate risk for pressure ulcer development, as indicated by a Braden Scale score of 14. The resident had severely impaired cognitive skills and required maximal assistance for mobility. Physician orders specified the use of a low air-loss mattress (LALM) for skin management. However, observations and interviews revealed that the LALM was set to 160 lbs, while the resident's actual weight was 115 lbs, as confirmed by both a CNA and LVN. The LALM setting was not adjusted according to the resident's weight, contrary to the manufacturer's guidelines and facility policy. Staff interviews confirmed that the LALM should have been set to 120 lbs based on the resident's weight, and that charge and treatment nurses were responsible for ensuring correct settings. The DON acknowledged that the incorrect LALM setting rendered the device ineffective in preventing pressure ulcers. Review of facility policy and the LALM operation manual further supported that mattress settings should be based on the resident's weight. This failure to ensure the LALM was set appropriately placed the resident at risk for the development of pressure ulcers.