Failure to Follow Ordered Low Air Loss Mattress Settings for Pressure Ulcer Management
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order and care plan interventions for a resident requiring a low air loss (LAL) mattress setting of 250. Surveyor observation showed the resident’s LAL pump was set above 300, with the static setting turned on. The resident’s medical record documented morbid obesity, cellulitis of the left lower limb, and paraplegia, and the quarterly MDS indicated the resident was at risk for pressure ulcers and had at least one unhealed Stage 4 pressure ulcer present on admission. A verbal physician order dated 07/26/25 directed that the LAL mattress be set at 250 every shift for wound care, with settings and function checked each shift. The resident’s care plan, initiated in 2022 and revised in 2026, also specified that the LAL mattress setting be kept at 250 as part of interventions for actual skin breakdown to the gluteal areas and excoriation to the buttocks. During interviews, the Infection Preventionist stated that LAL pump settings were based on resident weight unless otherwise ordered and confirmed that the pump was set between 300 and 350 with the static mode activated, which she said should only be used briefly for transfers and should not be on for this resident. An LPN reported that she checked the LAL pump each shift and believed it was set correctly at 250, referencing tape on the pump marked “250,” but upon inspection she confirmed the setting was between 300 and 350 with static mode on. After reviewing the physician orders, the LPN acknowledged the setting should have been at 250. The facility’s policy on support surfaces required licensed nurses to check powered devices each shift and as needed for proper functioning and inflation, and stated that support surfaces would be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. The observed pump setting and static mode use were inconsistent with the physician order, care plan, and facility policy, and the report states this placed the resident at risk of worsening pressure wounds, new wound development, and unmet care needs and goals.
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