Failure to Ensure Proper Functioning and Calibration of Low Air Loss Mattress for Resident With Pressure Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure proper functioning and calibration of a low air loss mattress for a resident with significant skin integrity issues. The resident had spastic hemiplegia, quadriplegia, amputations of the left foot and right leg above the knee, a history of wounds, and at the time had a Stage III sacral pressure ulcer, multiple venous ulcers on the left leg and stump, and a surgical wound on the right stump. The resident’s care plan included an intervention for a low air loss mattress, but there was no corresponding physician order or parameters for its use in the order summary. The manufacturer’s instructions for the Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress specified that the mattress should be kept in alternating pressure mode when the patient is lying down and that pressure should be set according to the patient’s weight using the weight setting buttons. Multiple observations showed the resident’s mattress alarm beeping on more than one occasion, indicating a malfunction, and later showed the mattress set at the highest weight setting despite the resident’s last recorded weight of 190.4 lbs. An LPN acknowledged the alarm indicated the mattress was not working correctly, admitted not knowing how to correct or calibrate it, and could not provide evidence of having contacted the equipment company as claimed. The resident and a medication aide both reported that the mattress had been beeping for weeks, and the interim DON and maintenance director stated they had not been informed of the issue until the survey date. The interim DON and maintenance director also reported not knowing how to calibrate the air mattress according to manufacturer instructions, and the mattress was instead adjusted based on the resident’s comfort rather than the resident’s weight, despite the presence of active wounds and the manufacturer’s specified weight-based settings.
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