Improper Use of Low Air Loss Mattress for Pressure Injury Care
Penalty
Summary
The facility failed to ensure that a low air loss (LAL) mattress was used according to professional standards of practice for a resident with a sacrococcyx pressure injury. During observation, the resident was found lying on a blue reusable pad (chux) placed on top of the LAL mattress. The resident's care plan included interventions to follow facility protocols for pressure injury treatment, and a physician's order specified the use of the LAL mattress with daily monitoring for proper setting, functioning, and placement. The LAL mattress operator's manual instructed that only a cotton sheet should be used to cover the mattress to avoid direct contact and improve comfort. Interviews with facility staff, including a CNA, LVN, and the DON, confirmed that the chux should not have been used with the LAL mattress, as it could interfere with the mattress's function and potentially affect the resident's comfort and healing. The facility's policy required that all residents receive care and services in accordance with evidence-based and accepted professional clinical standards. The use of the chux on the LAL mattress was inconsistent with these standards and the manufacturer's instructions.