Incorrect Low Air Loss Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when staff failed to set a low air loss mattress (LALM) at the correct weight setting for a resident who was at risk for pressure ulcer development. The resident, who had diagnoses including muscle weakness, sepsis, and chronic respiratory failure, was dependent on staff for most activities of daily living and had severe cognitive impairment. According to the physician's order and facility policy, the LALM was to be set based on the resident's weight, which was documented as 82 lbs. However, during observation, the LALM was found to be set at 50 lbs, which did not match the resident's actual weight. Staff interviews and record reviews confirmed that the LALM was not set according to the resident's current weight, as required by both the physician's order and the facility's pressure ulcer prevention policy. The DON acknowledged that setting the LALM below the resident's weight could put the resident at risk for skin breakdown. The care plan for the resident indicated interventions to administer treatments as ordered and monitor for effectiveness, but the incorrect mattress setting represented a failure to follow these interventions.