Incorrect Low Air Loss Mattress Setting for Resident with Pressure Ulcer
Penalty
Summary
A deficiency was identified when a resident with an unstageable pressure ulcer and deep tissue damage was found to have their low air loss mattress set incorrectly. The resident, who was severely cognitively impaired and dependent on staff for activities of daily living, weighed 76 lbs, but the mattress was set to support 320 lbs. This discrepancy was observed during a concurrent observation and interview with a Licensed Vocational Nurse (LVN), who confirmed the setting was inappropriate for the resident's weight. The manufacturer's instructions for the low air loss mattress specified that the pressure should be adjusted according to the resident's weight. The LVN acknowledged that the incorrect setting could result in skin breakdown and wounds. The failure to ensure the mattress was set correctly for the resident's weight constituted a lapse in providing appropriate pressure ulcer care and prevention.