Incorrect Low Air Loss Mattress Settings for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs), which are specialized air mattresses designed to prevent and treat pressure ulcers, were set to the correct weight-based settings for two residents. For the first resident, who had a history of peripheral vascular disease, chronic ulcers, dementia, and was dependent on staff for all activities of daily living, the LALM was observed to be set at 80 pounds, while the resident's actual weight was 103 pounds. Both the LVN and the DON confirmed that the mattress was not set correctly, and that incorrect settings would reduce the effectiveness of the mattress in managing skin integrity as ordered by the physician. For the second resident, who had diagnoses including metabolic encephalopathy, severe protein calorie malnutrition, diabetes, and a Stage 3 pressure ulcer, the LALM was set at 150 pounds, despite the resident weighing 103 pounds. A sticker on the mattress indicated the appropriate setting should be between 89-109 pounds. The RN and DON both acknowledged that the mattress was not set according to the resident's weight, which could compromise the intended pressure redistribution for skin management as per the physician's order. In both cases, the operator's manual for the LALM specified that the pressure setting should be adjusted according to the patient's weight, with clear guides provided on the device. The failure to set the LALMs correctly was confirmed through observation, interviews with nursing staff and the DON, and review of medical records and physician orders. This deficiency was identified through direct observation and record review by surveyors.