Improper Use of Linens and Incontinence Briefs on Low Air Loss Mattress
Penalty
Summary
The facility failed to follow proper protocol for the use of a low air loss mattress (LALM) for a resident with significant medical needs, including stage III and later stage IV pressure ulcers, sepsis, dementia, and dependence on a respirator. During observation, it was found that the resident was lying on a LALM with a fitted sheet and a cloth incontinence pad made of two different textures of linen, as well as wearing an incontinence brief. Staff confirmed that there were four layers of linen between the resident's back and the mattress surface, contrary to facility policy and physician orders, which specified no more than two layers and discouraged the use of fitted sheets and incontinence briefs on LALMs. Interviews with nursing staff and the Director of Nursing revealed awareness that multiple layers of linen and the use of incontinence briefs impede the effectiveness of the LALM by blocking airflow, which is essential for wound healing and prevention of further skin breakdown. Review of facility policy confirmed that only a single, loosely placed flat sheet should be used, and non-plastic backed pads should be selected to maintain airflow. The observed practice of using multiple linen layers and incontinence briefs did not align with these requirements, resulting in a deficiency related to pressure ulcer care and prevention.