Failure to Set Low Air Loss Mattress Correctly for Pressure Ulcer Management
Penalty
Summary
The facility failed to follow its policy and procedure on pressure ulcer prevention and wound management for one resident by not ensuring that the low air loss (LAL) mattress was set according to the resident's weight. The resident, who had a stage 4 sacral/coccyx pressure ulcer and was dependent on care for activities of daily living, was observed with the LAL mattress set at a firmness level appropriate for a much heavier individual (setting 4 for 175 lbs), while the resident's actual weight was 123 lbs, which required a lower setting (2 to 3). This discrepancy was confirmed through interviews with nursing staff, who acknowledged that the mattress was not set correctly and that this could impact the effectiveness of the pressure injury management. Record reviews showed that the resident's care plan and facility policy specifically required the use of the LAL mattress per manufacturer guidelines, including setting the firmness based on the resident's weight. Staff interviews and documentation confirmed that these guidelines were not followed, and the care plan intervention to educate staff on proper mattress settings was not implemented. The Director of Nursing also acknowledged that the failure to follow the care plan and manufacturer’s instructions could negatively affect the resident’s wound healing.