Improper Low Air Loss Mattress Setting Leads to Trochanter Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a low air loss mattress (LALM) was set according to a resident’s weight as ordered and care planned, resulting in an alteration in skin and reopening of fragile scar tissue on the right trochanter. The resident was initially admitted with diagnoses including sepsis, bilateral knee contractures, and muscle weakness, and a history and physical documented that the resident lacked capacity to understand and make decisions. Physician orders and active care plans for alteration in skin integrity and risk for pressure ulcers directed that the LALM be set according to the resident’s weight for wound management and pressure redistribution. Record review showed that the resident’s weight was 88 lbs, and the Treatment Administration Record for the month indicated that on one day shift the LALM was documented as set according to the resident’s weight. However, during observation in the resident’s room, surveyors found the LALM set at 120 lbs rather than at or below the resident’s current weight. Treatment nurses interviewed at the time of observation stated that the LALM setting should be based on the resident’s weight, that settings higher than the resident’s weight make the mattress firmer, and that for this resident a setting of 80 would have been appropriate, while 120 could be too firm. The DON similarly stated that the resident’s weight should always be higher than the LALM setting and that a higher setting could defeat pressure redistribution and potentially increase pressure on the skin. A change-of-condition assessment documented that the resident was noted with a change in skin condition during routine treatment, with the right trochanter area observed to be reopened at the site of previous fragile scar tissue, described as a small open area with minimal drainage and fragile surrounding skin. A subsequent skin issues document identified an in-house acquired Stage 1 pressure ulcer/injury on the rear right trochanter, with specific measurements and wound characteristics recorded. The facility’s policy on support surfaces directed staff to review the care plan and use redistributing support surfaces to prevent skin breakdown and provide pressure relief or reduction, and the LALM operator’s manual indicated that the mattress should be adjusted according to the patient’s weight or a health care professional’s suggestion. Despite these directives, the LALM was not maintained at a setting consistent with the resident’s weight and care plan interventions.
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