Incorrect Low Air Loss Mattress Settings for Resident With Stage IV Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a low air loss (LAL) mattress was correctly set according to the resident’s weight for a resident with a chronic stage IV pressure ulcer and identified risk for pressure ulcer development. On observation, the resident was found lying on a LAL mattress set at 600–1000 pounds, while the most recent documented weight was 187.8 pounds, meaning the mattress was set at least 412.2 pounds above the recommended setting. During the same observation, the resident reported that the mattress was not comfortable and described feeling as though lying on a cement floor. The facility’s own LAL mattress manual and policy indicate that the pressure/weight setting should be adjusted using the resident’s weight as a guide, and the facility’s pressure ulcer and wound prevention/management policy requires necessary treatment and services to promote healing and prevent new sores. The resident had multiple medical diagnoses including multiple sclerosis, gastrostomy status, urinary incontinence, neuromuscular dysfunction of the bladder, and urinary tract infection, with a BIMS score of 12 indicating moderately impaired cognition. A Braden assessment documented a score of 15, indicating mild risk for pressure ulcer development, and wound documentation showed a stage IV pressure ulcer with moderate serous drainage. The care plan identified the need for a Foley catheter due to urinary incontinence and poor healing of the sacral stage IV pressure ulcer. When interviewed, the LPN responsible for wound care stated that LAL mattresses are supposed to be set at the resident’s weight but was unsure of the specifics and acknowledged not being certified in wound care. Facility and external documents presented by surveyors, including CMS guidance on pressure-reducing support surfaces and residents’ rights materials, further outlined expectations that support surfaces be used to provide adequate pressure reduction and that the facility provide services to maintain residents’ highest practicable physical and mental health and a comfortable environment.
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