F0908

E

Improper Weight-Based Settings of Low Air Loss Mattresses

Palm Springs, California Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain proper use and settings of low air loss (LAL) mattresses for four of six residents reviewed, despite physician orders and facility policy requiring licensed nurses to monitor function, proper setup, and placement. LAL mattresses in the subacute unit were equipped with pumps whose air pressure is set according to resident weight, with yellow arrows placed on each pump by the Subacute Unit Coordinator (SAC) to indicate the correct setting. The facility’s policy on low-air-loss therapy beds states that these beds inflate to specific pressures based on the height and weight of the patient.

Surveyors observed multiple instances where the LAL pump settings did not match the indicated weight-based settings. For one resident weighing 117 lbs, the yellow arrow on the pump was placed between 80 and 160 lbs, but the dial was set at 400 lbs until RN 1 adjusted it to align with the arrow. For a second resident weighing 144 lbs, the yellow arrow was between 100 and 150 lbs, but the dial was set at 350 lbs on the “Firm” setting, which the SAC confirmed was incorrect. For a third resident weighing 150 lbs, the yellow arrow was between 80 and 160 lbs, but the dial was set at 400 lbs on the “Max” setting, which the SAC also verified was not correct. For a fourth resident weighing 183 lbs, the yellow arrow was at 200 lbs, but the pump was set at 285 lbs, which LVN 1 acknowledged was incorrect and resulted in an overinflated, hard surface.

Interviews confirmed that staff were aware of the requirement to set LAL pumps according to resident weight and to verify settings. RN 1 and the SAC explained that the yellow arrows were placed to guide staff to the correct setting based on weight, and that proper settings help relieve pressure on the skin and minimize the risk of pressure ulcer development. The SAC stated it was her expectation that the assigned LVN check and verify LAL pump settings at the beginning of each shift. LVN 1 stated he checks his residents’ LAL pumps at the beginning and end of his shift and after resident care, and verified he was assigned to one of the residents with an incorrect setting; he reported that he had checked the pump earlier and believed it was correct, and acknowledged he did not re-check the setting after providing wound treatment. LVN 1 also stated he did not think he checked the fourth resident’s mattress setting that day and acknowledged he should have. All four residents had severe cognitive impairment and physician orders for LAL mattresses with licensed nurses to monitor function, proper setup, and placement.