F0684

D

Improper Use of Air Loss Mattress and Lack of Staff Training

Kingsburg, California Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that an air loss mattress was used in accordance with the manufacturer’s instructions and that staff were trained and competent in its use for one resident. Surveyors found that the resident, who weighed 124.4 lbs, was lying on an air loss mattress with the weight setting dialed to 245–285 lbs. The Nurse Unit Manager (NM) confirmed during observation that the mattress was set at the maximum weight and acknowledged that this was not correct for the resident’s actual weight. The NM also stated that the mattress should be set according to the resident’s weight and that incorrect settings would affect the therapeutic effect of the mattress.

The resident had a significant medical history, including traumatic brain injury, status post ventriculoperitoneal shunt placement, hypertension, and venous thromboembolism. He had been admitted to a hospital for diaphoresis, shortness of breath, and high blood pressure, and was then readmitted to the facility for acute rehabilitation. The resident had experienced a fall at the facility on a prior date while on an air loss mattress, and the NM reported that the facility’s review of that fall did not identify any issues with the mattress settings or functionality at that time. However, during the current survey, the NM was unable to locate a physician’s order for the use of an air loss mattress for this resident.

When the LVN assigned to the resident was interviewed at the bedside, she confirmed that the mattress was set at 245–285 lbs and stated she was unsure what the settings should be for this resident. She indicated she did not know the resident’s current weight, only that he did not appear to weigh 245–285 lbs, and stated she believed she would need to check physician orders for the correct settings. Upon review of the medical record, the LVN verified the resident’s most recent weight of 124.4 lbs and acknowledged that setting the wrong weight on the air loss mattress was not acceptable and had the potential to cause pressure injuries and harm. She also stated she had not been aware that she should be checking the weight settings on the air loss mattress.

The Director of Staffing Development (DSD) reported that she was responsible for staff training and stated that staff were trained on the use of air loss mattresses and that correct weight settings were important. She agreed that a 245–285 lb setting for a resident weighing 124.4 lbs was not safe and not aligned with the instructions for use. However, upon further review, the DSD confirmed that she could not find any training or in-service records indicating that the LVN assigned on the day of the survey or the RN assigned at the time of the resident’s fall had received training on air loss mattress use. The Administrator (ADM) stated that the facility did not have a policy for air loss mattress use and that staff were expected to follow the manufacturer’s instructions. He also confirmed that there were no training records for the nurses assigned to the resident at the time of the fall and on the survey date.

Review of the manufacturer’s instructions for the air loss mattress showed that the mattress is intended for pressure injury treatment and prevention and that the dial should be set to the correct weight of the resident. The user manual warned that improper operation could cause injury and specified that only qualified personnel trained in the treatment and prevention of pressure injuries should operate the device. The ADM acknowledged that the resident’s mattress weight setting was not aligned with the instructions for use. The combination of an incorrectly set air loss mattress, lack of a physician order for its use, and absence of documented staff training or competency on air loss mattress operation constituted the deficiency identified by the surveyors.