Failure to Maintain Correct Air Mattress Setting for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified when a resident was observed lying on a low air mattress with the pump set to a weight setting significantly higher than the resident's actual weight. The air mattress pump was set past 360 pounds on the 'Firm' setting, while the resident's documented weight was 150.8 pounds. Nursing staff, including an RN, verified the incorrect setting and stated they were unaware of the facility's protocol for air mattress settings. The wound care technician confirmed that only specific staff members are authorized to change the air mattress settings and acknowledged that an incorrect setting could contribute to the development of pressure ulcers. The wound care coordinator further explained that low air mattresses are intended to promote wound healing and that improper settings can lead to wound decline. The resident in question had multiple diagnoses, including cerebral infarction, hemiplegia, mild neurocognitive disorder, and dysphagia, and was dependent on staff for all activities of daily living. The care plan identified a risk for skin integrity issues due to self-care deficits, impaired mobility, and comorbidities, and included interventions such as the use of a pressure redistribution mattress and frequent repositioning. Despite these interventions, there was no physician order for the low air mattress, and facility policy specified that such mattresses are to be used for residents with certain types of pressure ulcers. The manufacturer's manual indicated that the mattress should be set according to the resident's weight, which was not followed in this case.