Failure to Set Low Air Loss Mattress According to Resident Weight for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that two residents at high risk for pressure ulcers received care consistent with professional standards, specifically regarding the use of low air loss mattresses (LALM) set according to each resident's weight. For one resident with diagnoses including type 2 diabetes mellitus, diabetic neuropathy, adult failure to thrive, and on palliative care, the LALM was observed set at 130 lbs, while the resident's actual weight was 158 lbs and the manufacturer's instructions indicated the setting should be between 150-180 lbs. Both a CNA and an LVN confirmed the setting was incorrect and acknowledged the importance of matching the mattress setting to the resident's weight to prevent pressure injuries. The DON also confirmed that the LALM should be set according to the resident's weight and that staff are responsible for ensuring this is done. For a second resident with diagnoses including abnormalities of gait, muscle weakness, and chronic embolism and thrombosis, the LALM was observed set at 270 lbs, while the resident's weight was 152 lbs and the manufacturer's instructions indicated the setting should be between 120-150 lbs. An LVN confirmed the setting was incorrect and stated that improper settings could cause pressure injuries. The DON reiterated that the LALM should be set according to the resident's weight and that staff are responsible for monitoring and reporting any discrepancies. In both cases, the facility's policy and procedure, as well as the manufacturer's specifications, required the LALM to be set based on the resident's weight. The failure to follow these guidelines resulted in the residents not receiving care consistent with professional standards for the prevention of pressure ulcers, as confirmed by staff interviews and documentation review.