Failure to Properly Calibrate Low-Air Loss Mattresses for Residents with Pressure Ulcers
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 calibrated according to their individual weights. For one resident with multiple diagnoses, including Alzheimer's disease and a history of skin breakdown, the LAL mattress was set for a person weighing 355 pounds, while the resident's actual weight was 137.2 pounds. Nursing staff confirmed the incorrect setting and acknowledged that it was their responsibility to ensure the mattress was adjusted to the resident's current weight. The manufacturer's user manual specified that the mattress pressure should be set according to the patient's weight. Another resident, admitted with multiple wounds including pressure ulcers and weighing less than 100 pounds, was found to have an LAL mattress set for someone weighing 160 pounds. The treatment nurse verified the incorrect setting and confirmed that the mattress should have been adjusted to the resident's actual weight of 93.4 pounds. The resident's medical record included orders for pressure ulcer precautions and the use of a pressure-relieving mattress, but the settings were not properly adjusted as required. Interviews with nursing staff and the Director of Nursing (DON) confirmed that nurses were responsible for adjusting LAL mattress settings according to each resident's current weight. The DON acknowledged that staff did not follow the manufacturer's guidelines for the LAL mattresses and that her expectations for proper adjustment were not met. The failure to set the mattresses correctly was confirmed through observation, interview, and record review, and was identified as a deficient practice that could contribute to the worsening of wound conditions for the affected residents.