Failure to Maintain Correct Low Air Loss Mattress Settings for Pressure Ulcer Management
Penalty
Summary
The facility failed to maintain the appropriate settings on a Low Air Loss Mattress (LALM) for a resident who was re-admitted with a Stage 4 pressure ulcer of the sacral region. The physician's order specified that the LALM should be set between 250-280 lbs and checked every shift, based on the resident's weight of 250 lbs. However, during observation, the LALM was found set at 320 lbs, which was above the recommended range. The resident reported discomfort and stated that the mattress was too hard and was starting to hurt her bottom. Staff interviews confirmed that the LALM settings should match the resident's weight and that incorrect settings could impact wound healing. Further review of the operator's manual for the LALM confirmed that the pressure-adjust knob should be set according to the patient's weight. Multiple staff, including the Infection Preventionist, Treatment Nurse, and Director of Nursing, acknowledged that the settings were incorrect and that the mattress was firmer than intended, which could compromise its pressure-relieving function. The deficiency was identified through observation, interview, and record review, with direct evidence that the LALM was not set as ordered for wound management.