Failure to Set Air Mattress to Resident's Weight as Ordered
Penalty
Summary
A deficiency was identified when staff failed to ensure that an air mattress for a resident was set at the appropriate weight according to the manufacturer's instructions. The resident, who had multiple complex medical conditions including cerebral infarction, SIRS, diabetes, hemiplegia, anoxic brain damage, and was dependent on staff for all ADLs, had a physician's order for an air mattress with bolsters and specific wound care instructions. Despite the resident weighing only 165 pounds, observations on two consecutive days revealed the air mattress was set at 610 pounds. The operation manual for the mattress specified that the pressure range should be adjusted according to the resident's weight, with settings adjustable between 90 and 650 pounds. Staff interviews revealed that the LPN believed the mattress was set at 610 pounds based on a care plan to allow the resident to be elevated higher for television viewing, but the DON confirmed there was no documentation in the care plan supporting this preference. The discrepancy between the resident's actual weight and the mattress setting, as well as the lack of documentation for the deviation from standard practice, led to the deficiency in providing appropriate pressure ulcer care and prevention.