Incorrect Low Air Loss Mattress Setting for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set to the correct weight for a resident with a stage 4 pressure ulcer who required extensive assistance with turning and repositioning. During wound care observation, the wound care nurse was found to be unaware of how to adjust or unlock the mattress weight setting, which was locked at 400 pounds, despite the resident's actual weight being 265.8 pounds as documented in the medical record. The nurse acknowledged that the mattress setting should be checked daily and that an incorrect setting could result in increased pressure on the resident's wound. The resident in question had a significant medical history, including a stage 4 pressure ulcer extending from the left buttock to the sacrum and right buttock, requiring maximum staff assistance for bed mobility, toileting, and transfers. Facility policy and CMS guidance emphasize the importance of proper tissue load management and appropriate use of pressure-reducing support surfaces. The failure to adjust the mattress to the resident's actual weight resulted in the mattress being more firm than necessary, potentially increasing pressure on the wound area.