Incorrect Low Air Loss Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a low air loss mattress was set to the correct setting according to the wound care prevention protocol for a resident with multiple comorbidities and moderate cognitive impairment. The resident was readmitted with diagnoses including hypertension, diabetes, subdural hemorrhage, disc degeneration, epilepsy, anemia, malnutrition, and hepatic encephalopathy, and was identified as being at moderate risk for pressure ulcers. Upon admission, the resident had moisture-associated skin damage (MASD) to the sacrum and was assessed as chairfast and incontinent, with a care plan in place for pressure relief interventions, including the use of a low air loss mattress. During observation, the resident was found lying on a low air loss mattress set at 320, which did not correspond to the resident's actual weight, which was significantly lower. Interviews with staff revealed uncertainty about the resident's weight and the correct mattress setting. The LPN was unsure of the resident's weight and acknowledged that the mattress should be set based on weight, while the wound care technician confirmed that the setting was incorrect and planned to update the label with the correct weight. The wound care nurse also stated that the mattress should be set according to the resident's weight and that the current setting was too firm, potentially compromising the intended pressure relief. Facility policy and the manufacturer's instructions both require that the low air loss mattress be set according to the resident's weight to ensure proper pressure redistribution and skin protection. The failure to set the mattress correctly was observed and confirmed by multiple staff members, and the process for ensuring correct settings, including labeling and regular checks, was not followed at the time of the survey. This lapse had the potential to affect the resident's skin integrity and the effectiveness of the pressure ulcer prevention protocol.