Failure to Ensure Proper Use and Timely Replacement of Low Air Loss Mattresses
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for four residents who were at risk for or being treated for pressure injuries. For two residents, the low air loss mattresses (LALM) were not set according to the residents' current weight or comfort as indicated by both the facility's policy and the manufacturer's guidelines. In one case, a resident weighing 123 lbs was found lying on a LALM set at 240 lbs, despite a sticker on the pump indicating the correct setting should be 120 lbs. Staff confirmed that the mattress should have been set to match the resident's weight, and that failure to do so could affect comfort and increase the risk of pressure injury. Another resident's LALM was set at 160 when the correct setting, based on the resident's weight of 185 lbs, should have been 200, as confirmed by both nursing staff and the assistant director of nursing. For two additional residents, the LALMs were observed to be malfunctioning, with the pump units emitting a beeping sound and a flashing "low pressure" indicator light. Both residents appeared sunk into their beds, and staff confirmed that the mattresses had been in this state for over two hours. The staff and DON acknowledged that the mattresses were deflating or had leaks, and that the residents' buttocks were nearly touching the bed frame, which could lead to skin breakdown. The facility did not have extra LALMs readily available to replace the malfunctioning units, resulting in the residents remaining on inadequately functioning support surfaces for an extended period. All four residents involved had significant medical histories and were at moderate to very high risk for developing pressure injuries, as indicated by their Braden Scale assessments and physician orders for LALM use. The facility's own policies and the manufacturer's guidelines required that LALMs be set according to resident weight and that malfunctioning mattresses be promptly replaced to ensure proper pressure redistribution. The failure to follow these procedures resulted in residents being exposed to improper support surfaces, increasing their risk for the development or worsening of pressure injuries.