Failure to Maintain Correct LALM Settings for Pressure Ulcer Management
Penalty
Summary
The facility failed to maintain appropriate settings on Low Air Loss Mattresses (LALM) for three residents who were at risk for or had existing pressure ulcers. For one resident, the LALM was set at 230 lbs. despite the resident weighing 140 lbs., as observed by the Director of Nursing (DON). The DON confirmed that the setting was incorrect and should have matched the resident's actual weight, as per the manufacturer's guidelines. The DON acknowledged that the incorrect setting could potentially lead to the redevelopment of pressure ulcers. Another resident's LALM was found set at 350, while the resident's actual weight was 162 lbs. This discrepancy was identified during an observation with a Licensed Vocational Nurse (LVN), who admitted not knowing the resident's weight without checking the electronic medical record. The DON confirmed that the staff did not follow the care plan or manufacturer guidelines, and that the excessively high setting could worsen the resident's wounds. A third resident's LALM was observed set at 200 lbs., while the resident's weight was 159 lbs. The DON verified that this setting was incorrect and did not align with the physician's order or the manufacturer's instructions, which required the mattress to be set according to the resident's weight. In all three cases, the failure to set the LALM according to the residents' actual weights was directly observed and confirmed by facility staff, and the operational manuals for the devices specified that settings should be based on patient weight.