Failure to Set Pressure-Relieving Mattress According to Resident Weight
Penalty
Summary
The facility failed to ensure that a low air loss mattress (LALM), prescribed for a resident with multiple pressure ulcers and cellulitis, was set according to the manufacturer's recommendations and the resident's actual weight. The resident, who was cognitively intact and dependent on staff for activities of daily living, was observed lying on a LALM set at 340 pounds, despite weighing 214 pounds. The care plan specifically required the use of a LALM to enhance wound healing, and facility policy indicated that support surfaces should be adjusted to individual needs. During observation and interview, the treatment nurse confirmed that the LALM should be set to match the resident's weight for optimal pressure relief and was unable to explain why the setting was incorrect. Review of the manufacturer's manual supported the need to adjust the mattress based on the resident's weight. This discrepancy between the resident's actual weight and the LALM setting constituted a failure to follow both manufacturer guidelines and facility policy for pressure ulcer management.