Failure to Ensure Correct Low Air Loss Mattress Settings for Pressure Injury Prevention
Penalty
Summary
The facility failed to ensure that low air loss (LAL) mattresses were set to the correct weight settings for residents at risk for developing pressure injuries. Multiple observations revealed that staff members, including agency LPNs and wound care team members, were either unaware of the appropriate mattress settings or did not verify them according to manufacturer guidelines. For example, one resident's LAL mattress was set for 110 lbs despite the resident weighing only 84 lbs, and another mattress was set at 150 lbs for a resident weighing 98 lbs. In both cases, staff had to be prompted to adjust the settings to more appropriate levels. Residents involved in these incidents were identified as high risk for skin impairment, with documented histories of pressure injuries, chronic wounds, and comorbidities such as diabetes, vascular disease, and limited mobility. Care plans and physician orders specified the use of specialized mattresses and detailed wound care regimens, but the observed mattress settings did not align with these requirements. Staff interviews confirmed that the settings should be based on resident weight, and that incorrect settings could compromise the effectiveness of the mattresses. Facility policy required limiting the number of linen layers on LAL mattresses and using the correct settings to manage comfort, positioning, and moisture for residents with stage 3 or 4 pressure sores. Despite these policies, the survey found that three out of four residents reviewed for pressure injury prevention and treatment had LAL mattresses set incorrectly, indicating a systemic failure to follow established protocols for pressure ulcer prevention and care.