Failure to Maintain Proper LALM Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to maintain appropriate settings on Low Air Loss Mattresses (LALM) for two residents with significant risk factors for pressure ulcers. For one resident with contractures, diabetes, quadriplegia, and a gastrostomy, the LALM was observed to be set at 230 lbs, despite the resident weighing 153 lbs and manufacturer guidelines indicating a setting between 150-180 lbs. Staff interviews revealed that CNAs were not permitted to adjust the LALM, and there was confusion among nursing and maintenance staff regarding responsibility for the settings and the facility's policy. The Infection Control Nurse and Director of Nursing both acknowledged that incorrect LALM settings could result in the mattress being too hard, potentially causing or worsening pressure ulcers. Another resident, with diagnoses including stage 4 and stage 3 pressure ulcers, diabetes, and quadriplegia, also had a LALM set incorrectly. The resident weighed 135 lbs, but the LALM was observed set at 230 lbs, while a sticker on the pump indicated it should be set to 130 lbs. The treatment nurse stated that the LALM should be set based on the resident's weight and that she evaluated the settings daily, but was unaware of the current setting and was unsure of the facility's LALM policy. The care plan for both residents specified that the LALM should be set according to the resident's weight. Record reviews, observations, and staff interviews consistently showed a lack of adherence to physician orders and manufacturer guidelines for LALM settings. There was also a lack of clarity among staff regarding who was responsible for checking and adjusting the LALM, and insufficient knowledge of the facility's policy on LALM management. These actions and inactions led to the deficiency in providing appropriate pressure ulcer care and prevention.