Failure to Individualize and Monitor Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
Surveyors found that the facility failed to ensure proper pressure ulcer prevention and care for two residents who required alternating air mattresses. Both residents had physician orders for the use of these specialty mattresses, but the orders did not specify individualized settings based on the residents' current weights. Observations revealed that the mattresses were set at inappropriate weight settings, with one mattress set at 420 pounds for a resident weighing 76.5 pounds, and another set at an unspecified but clearly incorrect setting for a resident weighing approximately 117 pounds. Documentation on the Treatment Administration Record indicated that staff were checking for mattress inflation and function, but there was no documentation of the recommended mattress settings or verification that the settings matched the residents' weights. Interviews with staff, including CNAs, LPNs, and unit managers, revealed a lack of knowledge and responsibility regarding the proper use and monitoring of air mattresses. Staff reported that they only responded to alarms or called maintenance if there was an issue, and did not routinely check or adjust mattress settings. The wound care nurse and central supply staff indicated that mattresses were initially set up based on resident weight, but ongoing monitoring and adjustment were not consistently performed by nursing staff. The Assistant Director of Nursing acknowledged that prior to the survey, they were unaware that the mattresses had weight settings that needed to be checked. Both residents involved were at risk for pressure ulcers, with one having a history of left-sided paralysis and the other having active Stage 2 and Stage 4 pressure ulcers. The lack of individualized mattress settings and failure to monitor and adjust these settings as needed constituted a deviation from professional standards of practice, potentially impacting the prevention and healing of pressure ulcers for these residents.