Improper LAL Mattress Settings and Excessive Bedding for Pressure Injury Care
Penalty
Summary
The facility failed to provide necessary care and services to a resident with a pressure injury by not ensuring the proper use and settings of a low air loss (LAL) mattress. During observation, the resident was found lying on a LAL mattress that was set to static mode with a weight range of 200 to 250 pounds, despite the resident's actual weight being 107 pounds. The care plan and physician's orders specified that the mattress should be set to alternate mode when not providing ADL care and adjusted to one bar above 90 pounds. Staff interviews confirmed that the mattress settings were not in accordance with the care plan or the manufacturer's guidelines, and staff were unclear about the correct settings and their responsibilities in ensuring proper mattress function. Additionally, the resident was observed lying on multiple layers of bedding, an absorbent pad, and an incontinent brief while on the LAL mattress. Facility policy and staff interviews indicated that only one layer of sheet and either an incontinent pad or brief should be used to maximize the effectiveness of the LAL mattress. Staff acknowledged that having multiple layers of bedding and pads could defeat the purpose of the mattress and potentially impact wound healing. The resident in question had a history of severe cognitive impairment, was dependent on staff for ADLs and mobility, and had an unstageable pressure injury on the left hip. The wound was documented as healing with no signs of infection, but the improper mattress settings and excessive bedding layers were not in line with the care plan or facility policy, potentially compromising the resident's skin integrity and wound healing.