Failure to Set Pressure Mattress According to Resident Weight
Penalty
Summary
The facility failed to set the Alternating Pressure Mattress (APM) according to the resident's weight as specified in both the manufacturer's guidelines and the physician's orders. A review of the resident's records showed that the physician had ordered a Low Air Loss mattress for skin management, with instructions to monitor its function and settings every shift. During observation, the mattress was found set at 350 lbs, while a sticker on the bed indicated the correct setting should be between 120-180 lbs based on the resident's weight. Staff interviews revealed that the Licensed Vocational Nurse was unaware of the correct setting and deferred responsibility to the Treatment Nurse, who also confirmed the setting was incorrect and could not explain why it had been set improperly. The resident involved had a history of significant medical issues, including a previous unstageable pressure injury to the sacrococcyx, muscle wasting, and type 2 diabetes, and was assessed as being at continued risk for skin breakdown. The resident was also noted to have severely impaired cognition and required assistance with daily activities. Despite these risk factors and clear preventive measures outlined in the care plan, the mattress was not set appropriately, as required by both the physician's order and the manufacturer's instructions.