Failure to Follow Ordered Low Air Loss Mattress Settings for Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow a care plan intervention for a resident who required a low air loss (LAL) mattress to be set at 150. The resident was admitted with multiple diagnoses including Type 2 diabetes mellitus with foot ulcer, non-pressure chronic ulcers of both heels, midfoot, and right ankle, chronic kidney disease, hemiplegia following cerebral infarction, limited mobility, peripheral vascular disease, anemia, and hypertension. The resident’s care plan, initiated and later revised in the EMR, identified potential for impaired skin integrity and actual skin breakdown of the right medial foot and right heel, with an intervention specifying that the LAL mattress be set at 150. Surveyor review of an order listing provided by the DON showed that the physician-ordered LAL mattress setting for this resident was 150. However, during observation, the resident’s LAL mattress pump was found set between 200 and 240 instead of the ordered setting. The IP stated that LAL pump settings were based on resident weight unless otherwise specified in physician orders and that improper settings could affect wound healing. The UM reported that nurses and nurse aides were responsible for checking LAL mattresses during rounds to ensure they functioned appropriately. Facility policy on support surfaces required that powered devices be checked each shift and as needed for proper functioning and inflation, but the observed mattress setting did not match the physician order or care plan intervention.
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