Failure to Ensure Correct Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that residents at risk for pressure ulcers received necessary treatment and services consistent with professional standards of practice, specifically regarding the correct setting of air mattresses according to physician orders. For one resident with a stage 4 sacral pressure ulcer, severe cognitive impairment, and high risk for developing further ulcers, the air mattress was repeatedly observed set at the lowest setting (50 lbs), despite a physician order for a setting of 150 and a recent weight of 91.5 lbs. Multiple staff interviews confirmed that the mattress setting was too low and not in accordance with the physician's order or the resident's weight, and that this could affect skin integrity. Another resident, also severely cognitively impaired and dependent for positioning, was observed with an air mattress set at 380 lbs, while the physician's order specified a setting of 150 and the resident weighed less than 100 lbs. Staff interviews revealed that the mattress setting was not checked as required each shift, and the DON confirmed that physician orders for mattress settings were not followed. These failures were observed over multiple shifts and confirmed by staff, indicating a lack of adherence to established protocols for pressure ulcer prevention and care.