Incorrect Low Air Loss Mattress Settings for High-Risk Residents
Penalty
Summary
The facility failed to ensure that low air loss mattresses (LALMs), which are pressure-reducing devices, were set at the correct settings for two residents at high risk for pressure injuries. For one resident with functional quadriplegia and severely impaired cognition, the LALM was observed to be set at 200, despite a physician's order specifying a setting of 160 based on the resident's weight. Staff interviews confirmed that the setting was incorrect and should have been checked during daily rounds, but the discrepancy was not identified or corrected at the time of observation. Another resident, who was dependent for all activities of daily living and had a history of chronic respiratory failure and a stage 4 sacral pressure ulcer, was found lying on a LALM set at 400 lbs, while the resident's actual weight was 107 lbs and the physician's order specified a setting of 80. Staff interviews indicated that the correct mattress setting is essential for effective pressure redistribution and prevention of further skin breakdown, and that the mattress should be set according to the resident's actual weight as per facility policy and manufacturer instructions. Record reviews, staff interviews, and direct observations confirmed that the facility did not follow its own policy and physician orders regarding the adjustment of LALM settings based on resident weight. The failure to maintain correct mattress settings was observed for both residents, and staff were unable to provide an explanation for the discrepancies at the time of the survey.