Improper Low Air Loss Mattress Setting for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a low air loss (LAL) mattress was set according to the manufacturer’s weight-based guidelines for a resident with significant skin integrity risk. The resident, admitted with complete paraplegia and dependent or requiring extensive assistance for most ADLs, had an active care plan and physician order directing use of a LAL mattress for skin impairment prevention, with licensed nurses to monitor placement and functioning every shift. The manufacturer’s Dynarex LAL mattress manual specified that mattress settings should correspond to patient weight and that a low-pressure light and alarm would activate when pressure fell below the preset level. During an observation and interview, an LVN responded to the resident’s call light and found the LAL mattress alarm sounding and the low-pressure indicator flashing red. On inspection, the LVN identified that the mattress was incorrectly set at 350 lbs, while the resident’s actual weight was 106 lbs. The LVN stated the mattress should have been set to the resident’s current weight and that the treatment nurse was responsible for verifying correct settings during rounds. The DON confirmed that an incorrectly set LAL mattress can negatively impact a resident’s skin management and overall pressure injury prevention plan. The facility’s ADL policy required provision of hygiene and toileting services and interventions in accordance with assessed needs and recognized standards of practice, but the mattress setting and monitoring did not follow the manufacturer’s instructions or the resident’s care plan and orders.
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