Failure to Set and Maintain Pressure Relieving Mattress per Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure that a pressure relieving air mattress was set according to the resident's weight and maintained per the manufacturer's guidelines for a resident with a history of pressure ulcers and multiple comorbidities, including suspected deep tissue injury, peripheral vascular disease, anemia, chronic kidney disease, vascular dementia, hemiplegia, protein-calorie malnutrition, and diabetes. The resident's care plan and medical records indicated the use of an air mattress as an intervention for impaired skin integrity, with the resident weighing 174.5 pounds. However, observations revealed that the mattress was set at a level intended for residents weighing 441-500 pounds, rather than the correct setting for the resident's weight range of 163-244 pounds as specified by the manufacturer's label and manual. Despite staff documenting that the mattress was checked every shift and no issues were noted, the incorrect setting persisted, and the service light on the mattress was illuminated, indicating the need for service after a certain number of hours of use. Interviews with staff, including the ADON and CNA, confirmed a lack of awareness regarding the correct weight-based setting and the significance of the service light. The facility was not tracking the service light or notifying the rental company when it was activated, as required by the manufacturer's guidelines. These actions and inactions resulted in the failure to provide appropriate pressure ulcer care and prevention for the resident.