Failure to Set Low Air Loss Mattresses to Resident Weight
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs) for three of four sampled residents were set according to each resident's actual weight, as required by both facility policy and the manufacturer's instructions. Observations and interviews revealed that the LALMs for these residents were set at weights significantly higher than the residents' actual weights, resulting in mattresses that were too firm. This practice was confirmed by both the treatment nurse and the director of nursing, who acknowledged that the mattresses should be set to match the resident's weight to provide appropriate pressure redistribution. One resident, with a history of hemiplegia, hemiparesis, respiratory failure, and dementia, was observed on a LALM set at 350 lbs despite weighing only 123 lbs. Another resident, who had hemiplegia, hemiparesis, and a stage four pressure ulcer, was also found on a LALM set at 350 lbs while weighing 159 lbs. A third resident, diagnosed with quadriplegia and diabetes, was observed on a LALM set at 230 lbs, though his weight was 156-157 lbs. In each case, staff confirmed that the LALM settings were incorrect and not in accordance with the residents' actual weights. The facility's own policy and the LALM manufacturer's manual both require that the mattress pressure be adjusted based on the patient's weight to prevent skin breakdown and pressure ulcers. Staff interviews indicated awareness of the importance of correct LALM settings, yet the deficiency persisted across multiple residents. The incorrect settings had the potential to compromise the effectiveness of the pressure redistribution, as noted by the staff and the director of nursing during interviews.