Incorrect Low Air Loss Mattress Setting for Resident
Penalty
Summary
A resident with multiple medical conditions, including paraplegia, morbid obesity, type 2 diabetes, and a history of poor wound healing, was admitted to the facility and required a low air loss mattress for skin management as per physician orders. Upon review, it was found that the mattress was set for a weight range of 600 to 1000 pounds, while the resident's actual weight was 246 pounds. This incorrect setting was confirmed by both a Licensed Vocational Nurse and the Director of Nursing, who acknowledged that the mattress should have been set according to the resident's current weight. The facility's policy on the prevention of pressure injuries specifies the use of specialized mattresses as an intervention to prevent skin breakdown. However, the failure to set the mattress correctly for the resident's weight constituted a lapse in following this policy. The deficiency was identified through observation, interview, and record review, and it was confirmed that the mattress setting was not appropriate for the resident's needs at the time of the survey.