Incorrect Low Air Loss Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that a resident at risk for skin breakdown had a low air loss mattress (LALM) set to the appropriate settings as required by their care plan and physician orders. The resident, who had multiple diagnoses including bladder cancer, limb absence, osteoarthritis, and intervertebral disc degeneration, was identified as having a potential for skin breakdown and required a pressure-redistribution mattress. Observations revealed that the LALM was set at 320 lbs, which did not correspond to the resident's actual weight, and was in static mode rather than alternating mode as recommended by the manufacturer. The resident was unaware of the purpose of the mattress, and the treatment nurse confirmed the settings were incorrect and could impact the effectiveness of pressure relief. Further review of the resident's records, including the care plan and Minimum Data Set (MDS), confirmed the need for a pressure-reducing device and moderate assistance with mobility. Interviews with staff, including the treatment nurse and the Director of Staff Development, acknowledged the importance of correct LALM settings based on resident weight to prevent pressure injuries. The facility's policy and the manufacturer's instructional video both emphasized the necessity of adjusting the mattress to the resident's weight and using the appropriate mode to provide effective pressure redistribution. The failure to follow these protocols constituted the deficiency.