Failure to Ensure Correct Low Air Loss Mattress Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALM) were set to the correct settings for two residents, both of whom required specialized support surfaces for wound care or prevention of pressure ulcers. For one resident with a history of diabetes and bilateral above-knee amputations, who was severely cognitively impaired and required total assistance, the LALM was observed to be set to static mode rather than the alternating mode as recommended for wound management. Nursing staff had not checked the mattress setting that morning, and the physician's order did not specify the required mode. The treatment nurse confirmed that the alternating mode was necessary to prevent constant pressure on the skin, which could increase the risk of pressure ulcers. For another resident with diabetes and a right femur fracture, who was at risk for pressure ulcers and required maximal assistance, the LALM was found to be set at a weight setting of 280 lbs instead of the recommended 120 lbs based on the resident's body weight. The certified nursing assistant had not checked the setting at the start of her shift and only adjusted it after being prompted. The physician's order for this resident also lacked clarification on the specific setting level or mode, but the treatment nurse confirmed the correct setting should match the resident's weight as posted on the pump unit. Facility policy and the user manuals for the LALM systems indicated that mattress settings should be adjusted according to the resident's weight and clinical needs, and that alternating mode is used to minimize pressure on the skin. The Director of Nursing stated that settings should be individualized for each resident to promote wound healing or prevent skin breakdown, and that failure to follow recommended settings could place residents at risk for further pressure ulcers.