Failure to Maintain Proper Low Air Loss Mattress Settings for Pressure Ulcer Care
Penalty
Summary
The facility failed to maintain appropriate settings on Low Air Loss Mattresses (LALM) for two residents, both of whom were at risk for or had existing pressure ulcers. For one resident with a Stage 4 pressure ulcer and severe cognitive impairment, the LALM was set at 450 lbs, despite the resident weighing only 127 lbs. Both the licensed nurse and the Director of Nursing confirmed that the mattress should have been set according to the resident's actual weight, as specified in the physician's order, care plan, manufacturer’s instructions, and facility policy. The incorrect setting was observed during a room visit and acknowledged as improper by staff. For the second resident, who had multiple diagnoses including severe cognitive impairment, malnutrition, and was dependent on staff for most activities of daily living, the LALM was also set at 450 lbs, while the resident weighed 137 lbs. Additionally, there was no physician’s order for the LALM at the time of admission, and the order was not placed until several days later. Staff interviews revealed that nurses were aware of the need for physician orders and proper settings based on resident weight, but these procedures were not followed. Both cases were documented through observation, interviews with nursing staff and administration, and review of medical records, care plans, and facility policies. The facility’s own procedures and the manufacturer’s guidelines require LALM settings to be based on resident weight and a physician’s order, particularly for residents who are cognitively impaired or non-verbal. These requirements were not met for the two residents, resulting in a failure to provide appropriate pressure ulcer care and prevention.