Improper Low Air Loss Mattress Setting for Resident With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services to prevent the development or worsening of pressure injuries for one resident with existing pressure ulcers. Facility policy on Pressure Injury Prevention and Management, revised 9/2023, required evidence-based interventions for residents at risk or with pressure injuries, including use of appropriate pressure-redistributing devices and support surfaces. The Apex Domus 4 low air loss mattress manual specified that mattress pressure settings should be adjusted according to the resident’s weight and height to avoid bottoming out. The resident’s medical record showed orders for a low air loss mattress for wound management with placement and settings to be checked every shift, as well as detailed wound care orders for unstageable pressure ulcers on both elbows and a stage 4 pressure ulcer on the mid lower back. During an observation and concurrent record review, the resident was found on a low air loss mattress set at 450 psi, while the resident’s current weight was documented as 162 pounds. The LVN present confirmed that the mattress setting was incorrect for the resident’s weight and stated that the setting had been at that level “for a while.” The facility’s Administrator and DON were later informed of and acknowledged these findings. The failure to ensure the low air loss mattress was properly set in accordance with the resident’s weight constituted noncompliance with the facility’s own pressure injury prevention policy and the physician’s order to check mattress placement and settings every shift.
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