Failure to Follow LALM Protocols for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide care consistent with professional standards to prevent pressure ulcers for a resident who was at risk due to multiple medical conditions, including diabetes mellitus, heart failure, and severe cognitive impairment. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. Despite a physician order for a low air loss mattress (LALM) to manage and prevent pressure ulcers, staff placed multiple layers of linen and padding—totaling eight layers—between the resident and the LALM, contrary to both the manufacturer's instructions and facility policy, which specified no excessive padding should be used. Observations and interviews revealed inconsistent understanding among staff regarding the correct number of linen layers to use with the LALM. A CNA identified eight layers, while an RN believed four layers were appropriate, and the Infection Preventionist and DON both stated that only two layers, including the incontinence brief, should be present. Facility policy and the LALM operation manual both emphasized the importance of avoiding excessive padding to prevent interference with the mattress's pressure-relieving function. This failure to follow established protocols had the potential to contribute to the development or worsening of pressure ulcers for the resident.