Incorrect LAL Mattress Setting for Pressure Ulcer Management
Penalty
Summary
A resident with a history of a stage 4 pressure ulcer of the sacral region, who was dependent on staff for activities of daily living and had severely impaired cognitive skills, was admitted and readmitted to the facility. Physician orders and the resident's care plan specified the use of a low air loss (LAL) mattress for wound management, with instructions to determine and set the appropriate mattress settings based on the resident's needs. The manufacturer's guide for the LAL mattress indicated that the mattress should be set according to the patient's weight or comfort level. During an observation, the resident was found asleep in bed with the LAL mattress set to 225 lbs, despite a sticker on the mattress indicating it should be set to 87 lbs. This incorrect setting was confirmed by a Licensed Vocational Nurse, who acknowledged the discrepancy. The Director of Nursing also confirmed the importance of correct mattress settings for pressure ulcer prevention and management. The facility's policy emphasized the use of appropriate pressure-redistributing support surfaces for residents at risk or with existing pressure injuries. The failure to set the LAL mattress to the correct setting constituted a deficiency in providing appropriate pressure ulcer care.