Improper Linen Use on Low Air Loss Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow established guidelines for linen use on a low air loss mattress (LALM) for a resident at high risk for pressure injuries and with an existing Stage 4 pressure injury. The resident had severe cognitive impairment, lacked decision-making capacity, and was dependent on staff for all ADLs, including hygiene and positioning. Clinical documentation showed the resident was at high risk for pressure injuries per the Braden Scale and had a Stage 4 pressure injury on the left trochanter. Provider orders directed the use of a P.R.O. Plus LALM for wound management, and the facility’s educational materials and staff statements indicated that only a thin sheet and a disposable pad should be used under residents on a LALM to avoid interfering with pressure redistribution. During observations in the resident’s room, surveyors noted that multiple layers of linens and pads were placed between the resident and the LALM, including a thin white sheet, a folded white sheet, a green pad, and a disposable pad at one time, and later a thin sheet, a folded sheet, and a disposable pad. A CNA acknowledged that only a thin sheet and disposable pad were supposed to be used and admitted placing an extra green pad earlier to assist with repositioning during wound treatment and leaving a folded sheet under the disposable pad to make it easier to pull the resident up in bed, despite knowing this was not correct. The treatment nurse and DON confirmed that additional linen layers under a resident on a LALM reduced the mattress’s effectiveness in offloading pressure and that staff had been educated to minimize linen layers. The facility’s user manual for the P.R.O. Plus support surface allowed for specific items such as a draw or slide sheet and an incontinence barrier pad, but the observed practice exceeded these guidelines, leading to the cited deficiency.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.