Failure to Maintain Inflated Low Air Loss Mattress for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a low air loss mattress (LALM), prescribed for wound management and pressure ulcer prevention, remained inflated for a resident with multiple pressure-induced deep tissue injuries. The resident, who was admitted with diagnoses including muscle wasting, atrophy, and pressure ulcers on the sacral region and both heels, was observed in bed with a deflated LALM. The resident reported that the bed was hard, indicating the mattress was not functioning as intended. Interviews with nursing staff revealed that it was the responsibility of Certified Nursing Assistants (CNAs) to notify the charge nurse if the mattress was not inflated, and for nursing staff, including the treatment nurse and LVN, to ensure the mattress was properly set up and functioning. Despite these responsibilities, the treatment nurse admitted to not checking the mattress during a recent visit, and the Director of Nursing confirmed that a non-functioning LALM could hinder its preventive purpose. Facility policy required the use of appropriate pressure-relieving devices for residents at risk for skin breakdown, but this was not followed in this instance.