Failure to Set Low Air Loss Mattress to Resident's Weight
Penalty
Summary
The facility failed to ensure that a low air loss mattress (LALM) for a resident was set according to the resident's actual weight, as required for proper pressure ulcer prevention. The resident, who had diagnoses including metabolic encephalopathy, cerebral infarction, and dementia, was severely cognitively impaired and dependent on staff for all activities of daily living. The resident's care plan and physician orders specified the use of a LALM for skin management, and the Braden Scale assessment indicated the resident was at risk for developing pressure sores. Despite this, observations over multiple days revealed that the LALM was set for approximately 200 pounds, while the resident's actual weight was 104 pounds, as confirmed by the treatment nurse and documentation. Interviews with the treatment nurse and DON confirmed that the LALM should have been set within the 100-150 pound range, as indicated on the pump and by a note attached to it. Both staff members acknowledged that setting the LALM outside the appropriate weight range would make the mattress too firm, which could contribute to the development of pressure ulcers. Review of the manufacturer's user manual also confirmed that the pressure setting should be adjusted according to the resident's weight. The failure to set the LALM correctly represented a lapse in following established protocols for pressure ulcer prevention for a resident with a history of fragile skin and previous pressure ulcers.