Incorrect LAL Mattress Setting for Resident with Pressure Injuries
Penalty
Summary
A resident with a history of paraplegia, recent genitourinary surgery, urinary retention, and existing pressure injuries on the left ischium and right heel was admitted to the facility and assessed as being at moderate risk for pressure injuries. The resident required a low air loss (LAL) mattress as part of their care plan to manage and prevent further skin breakdown. According to the resident's current weight of 197 pounds, the LAL mattress was supposed to be set according to the manufacturer's guidelines, which specify adjusting the mattress pressure based on the patient's weight. During observation and interview, it was found that the LAL mattress was incorrectly set for a 300-pound person, rather than the resident's actual weight. The treatment nurse acknowledged responsibility for ensuring the correct mattress setting and admitted to forgetting to adjust it that morning. The DON confirmed that the mattress should have been set according to the resident's weight and that the incorrect setting could delay healing of existing pressure injuries and potentially result in new ones. Facility policy and manufacturer guidelines both require the LAL mattress to be set according to the resident's weight.