Failure to Set Pressure-Reducing Mattress to Resident's Weight
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's low air-loss mattress, intended to reduce the risk of pressure ulcers, was set within the resident's current weight range as required. The resident, who had diagnoses including Alzheimer's disease, insomnia, anxiety, and speech/language deficits, was severely cognitively impaired and dependent on staff for most activities of daily living. The resident was identified as being at risk for skin breakdown and pressure ulcers, with care plans and assessments indicating the use of pressure-reducing devices and a repositioning program. Despite these interventions, observations over several days revealed that the mattress was consistently set to 200 lbs, while the resident's documented weight was 122 lbs. The care plan lacked specific instructions regarding the correct mattress settings. Interviews with nursing staff and administrative personnel confirmed that the mattress should have been set according to the resident's current weight and that staff were expected to check the settings each shift. The facility's wound management policy required assessment of pressure ulcer risk and implementation of preventative interventions, but the failure to set the mattress appropriately represented a lapse in following these protocols. This inaction placed the resident at risk for complications related to skin breakdown and pressure ulcers.