Failure to Set Low Air Loss Mattress According to Resident Weight
Penalty
Summary
A deficiency occurred when a resident with a stage 4 sacral pressure ulcer was not provided care consistent with professional standards to prevent further pressure injury. The resident, who was alert and able to communicate, required total assistance with all activities of daily living and was at high risk for pressure injuries due to mobility issues. Upon observation, the resident's low air loss mattress (LALM) was set at 350 lbs, which is the firmest setting, despite the resident's actual weight being 124 lbs. The resident reported discomfort, stating the bed was too hard, and the attending nurse confirmed that the LALM should be set according to the resident's weight and comfort. The Director of Nursing also acknowledged that the mattress should have been set to the resident's weight to prevent worsening of pressure ulcers. Facility policy and the manufacturer's guidelines both require that the LALM be set according to the resident's weight to ensure proper pressure redistribution and prevention of new or worsening pressure ulcers. However, the staff failed to adjust the mattress setting appropriately, leaving the resident at risk for further skin breakdown. This failure was identified through observation, interviews with staff and the resident, and review of medical records and facility policies.