Failure to Ensure Proper Low Air Loss Mattress Settings and Maintenance
Penalty
Summary
The facility failed to ensure proper use and maintenance of low air loss mattresses (LALM) for two residents with significant risk factors for pressure ulcers. For one resident with chronic respiratory failure, sepsis, severely impaired cognition, and total dependence on staff for activities of daily living, the LALM was set incorrectly. The mattress was observed at a setting and weight of 180 lbs, while the resident's actual weight was 115 lbs, and the physician's order specified a different setting. The treatment nurse confirmed the discrepancy and acknowledged that the incorrect setting could compromise skin integrity. For another resident with tracheostomy and gastrostomy status, non-verbal and fully dependent on staff, the LALM device was missing the pressure adjustment knob, making it impossible for staff to set the mattress pressure as ordered by the physician. The registered nurse confirmed the absence of the knob and stated that it should have been reported immediately to prevent further skin breakdown, especially since the resident already had a stage 1 pressure ulcer on the sacrum. The director of nursing also acknowledged that staff should have noticed and reported the missing knob during routine checks. Facility policy and manufacturer instructions require proper assessment, monitoring, and maintenance of LALM equipment to prevent pressure injuries. In both cases, the facility did not follow these protocols, resulting in the use of improperly set or unadjustable mattresses for residents at high risk for pressure ulcers.