Failure to Update Low Air-Loss Mattress Settings to Current Resident Weight
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s low air-loss mattress settings and corresponding physician’s order were updated to reflect the resident’s current weight, as required for appropriate pressure ulcer prevention and wound management. Facility policy titled “Support Surface Guidelines” stated that redistributing support surfaces are intended to prevent skin breakdown, promote circulation, and provide pressure relief or reduction for bed- or chairbound residents. Medical record review showed that the resident was readmitted to the facility and had a physician’s order, dated several months earlier, for a low air-loss mattress for wound care and management, with the mattress setting ordered at 99 lbs every shift. A skin assessment documented that the resident had a surgical wound on the left buttock and was on a properly functioning low air-loss mattress. Subsequent review of the resident’s Weights and Vitals Summary showed the resident’s current weight was 115 lbs. However, during observations in the resident’s room, surveyors found the low air-loss mattress was set at 120 lbs, and the ADON confirmed that both the physician’s order and the mattress setting had not been updated to reflect the resident’s current weight of 115 lbs. The Administrator and DON later acknowledged these findings. The report states that this failure had the potential for the resident to develop pressure ulcers or for existing pressure ulcers to worsen.
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