Failure to Set Low Air Loss Mattress to Resident's Weight
Penalty
Summary
A deficiency occurred when staff failed to ensure that a low air loss mattress (LALM) was set according to a resident's actual weight. Multiple observations revealed that the LALM was set at 305 lbs, while the resident's documented weight was 100 lbs. Interviews with nursing staff confirmed that the mattress should be adjusted to the resident's weight to provide appropriate pressure redistribution. The facility's own policy and the manufacturer's user manual both required the LALM to be set according to the individual's weight. Despite these requirements, the mattress remained set at a much higher weight, resulting in a firmer surface than appropriate for the resident. The resident involved had significant medical conditions, including end stage renal disease, type 2 diabetes with polyneuropathy, and chronic obstructive pulmonary disease. The resident was dependent on staff for activities of daily living and had a stage 4 pressure ulcer on the sacral coccyx. Staff interviews acknowledged that the incorrect mattress setting could increase pressure on the resident's existing wound and body, contrary to the intended use of the LALM for wound healing and pressure ulcer prevention.