Failure to Adjust LAL Mattress Settings According to Resident Weight
Penalty
Summary
The facility failed to provide adequate care and services to promote healing and prevent pressure ulcers for two residents who were observed lying on low-air loss (LAL) mattresses that were not correctly adjusted according to their individual weights. Both residents had orders for LAL mattresses as a preventative intervention due to a history of pressure injuries, and manufacturer guidelines required the mattress settings to be adjusted based on the resident's current weight. Observations and interviews confirmed that the mattresses for both residents were set at weights significantly higher than their actual documented weights, contrary to the requirements outlined in the user manual and physician orders. One resident, with a history of multiple diagnoses including palliative care, vascular dementia, and stage 3 pressure ulcers, was found lying on a LAL mattress set at 265 lbs, while her most recent recorded weight was 112.2 lbs. Nursing staff confirmed that it was their responsibility to ensure the mattress was set according to the resident's current weight and acknowledged that the incorrect setting could compromise the effectiveness of the mattress in preventing skin breakdown. The treatment nurse and DON both verified that the mattress was not set appropriately and that the order specified adherence to manufacturer guidelines. Another resident, with diagnoses including cerebral palsy, obesity, and a history of pressure injuries, was observed on a LAL mattress set at more than 350 lbs, while her documented weight was 153.4 lbs. Nursing staff and the DON confirmed that the mattress was not set according to the resident's current weight, as required. Both residents' care plans and orders specified the use of LAL mattresses for skin management and required monitoring per manufacturer specifications, which was not followed. The DON acknowledged that nursing staff did not meet expectations for monitoring and adjusting the mattress settings as required.