Failure to Set LAL Mattress Pressure According to Resident Weight
Penalty
Summary
The facility failed to ensure that residents received necessary care and services to prevent the development and worsening of pressure injuries and to promote the healing of existing pressure injuries. Specifically, the facility did not consistently set low air loss (LAL) mattress pressure levels according to residents' weights, as required by both manufacturer recommendations and facility policy. Observations revealed that several residents were lying on LAL mattresses with pressure settings that did not correspond to their current weights, which could impact the effectiveness of the mattresses in preventing and treating pressure ulcers. For example, one resident was observed on a LAL mattress set at a pressure level intended for a much higher weight than the resident's actual weight, and the resident reported discomfort. Another resident, who was nonverbal and unable to express comfort, was found on a mattress set at a level for a significantly higher weight than their own, with staff acknowledging the discrepancy. In some cases, the mattress settings were changed between observations, but still did not match the residents' actual weights. Additionally, there were instances where physician orders for the use of LAL mattresses were missing from the medical record, despite the mattresses being in use. Interviews with nursing staff and facility leadership confirmed that the LAL mattress settings should be based on resident weight and comfort, and that the observed discrepancies were not in line with facility policy or manufacturer guidelines. Staff acknowledged the importance of correct mattress settings for therapeutic benefit and comfort, and verified that the settings observed did not match the residents' documented weights. The failure to follow established protocols for LAL mattress use was observed in multiple residents, including those with cognitive impairment and those at high risk for pressure ulcers.
Plan Of Correction
The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Residents 98, 122, 28, and 131 were identified as impacted by this concern. On 7/17/2025, the Director of Nursing (DON) and Unit Manager assessed and adjusted all low air loss (LAL) mattress settings to correspond with each resident's weight. For residents able to communicate, staff inquired about comfort level, and settings were adjusted based on resident preference as needed. For residents unable to clearly express comfort level, mattresses remained set according to weight-based recommendations. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents using LAL mattresses were considered potentially affected. On 7/16/2025, the DON and designee compiled a list of all residents with LAL mattresses and ensured settings were reviewed and adjusted to align with each resident's current weight. For those who could communicate, adjustments were made based on individual feedback regarding comfort. Residents unable to verbalize preferences remained on weight-based settings. All mattress settings were reviewed and reflected in the residents' care plans. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurses about facility policy and procedure for Low air loss mattress (LAL) setting and to update resident's plan of care if resident's has preferred setting based on their comfort level. On 7/21/2025-7/25/2025, DSD in-serviced all CNA about policy and procedure for low air loss mattress setting to consult licensed nurse if LAL needed to be adjusted during care. Measures Put Into Place to Provide Systemic Changes in the Facility: The DON or designee will oversee ongoing monitoring of LAL mattress settings. Treatment nurses or designee will ensure that mattress settings are initially established based on resident weight. Adjustments will be made if a resident communicates discomfort. For residents unable to communicate, settings will remain at weight-based recommendations unless otherwise directed. A current list of residents with LAL mattresses and corresponding settings will be maintained and reviewed weekly. Updates to orders and care plans will be made as necessary. How the Facility Plans to Continue Monitoring: The DON or designee will review mattress settings and related documentation on an ongoing basis. Any discrepancies or concerns will be addressed promptly. Findings and compliance status will be reported during the monthly Quality Assurance (QA) meetings on 8/14/2025 and for a minimum of three months. Corrective action completion date: 8/23/2025 The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 5 was affected by this deficient practice. Resident 5 is currently not in the facility.