Failure to Set Low Air Loss Mattress According to Resident Weight
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was set up accurately according to the manufacturer's instructions for a resident with a history of a Stage 4 sacral pressure ulcer and morbid obesity. The resident's care plan and physician orders specified that the LAL mattress settings should be adjusted based on the resident's weight and personal preference. However, during observation, the mattress was found to be set at a weight setting between 350 lbs to firm, while the resident's actual weight was 144 lbs. Multiple staff members, including the Director of Staff and Development and the Infection Prevention Nurse, confirmed that the mattress was not set according to the resident's actual weight, as required by both the care plan and the manufacturer's user manual. The resident was dependent on staff for most activities of daily living and had impaired skin integrity related to a sacral coccyx Stage 4 pressure injury. During interviews, the resident reported that the bed was not as firm as before, indicating a change in the mattress setting. The Director of Nursing also acknowledged that the LAL mattress needed to be set based on the resident's weight and comfort level to prevent deterioration of wounds or development of new pressure injuries. The user manual for the mattress confirmed that the pressure should be adjusted using the patient's weight as a guide.