F0686

D

Improper Programming of Low Air Loss Mattresses for Residents With Pressure Injuries

Rockford, Illinois Survey Completed on 12-10-2025

Penalty

No penalty information released

Summary

The facility failed to ensure low air loss mattresses were correctly programmed according to residents' weights for multiple residents with pressure injuries. One resident with a Stage 4 pressure injury to the coccyx had a care plan listing a pressure-reducing low air loss mattress as an intervention, with no documentation that the resident requested a specific mattress setting. The resident’s recorded weight was 101 lbs, yet observations on two consecutive days showed the mattress programmed for a 350-lb setting. Another resident with a Stage 4 pressure injury to the medial right knee also had a care plan including a low air loss mattress, with no documentation of any resident request for a specific setting. This resident weighed 81.4 lbs, but observations on two days showed the mattress programmed for a 400-lb setting.

A third resident with pressure injuries to the left ischium and coccyx had a care plan that included a low air loss mattress as a pressure-relieving intervention, again without documentation that the resident requested a specific setting. This resident weighed 205.3 lbs, but observations on two days showed the mattress programmed for a 400-lb setting. The wound care nurse stated that low air loss mattresses should be programmed to the correct resident weight so the mattress can help heal or prevent pressure injuries, and that if the weight is set too high, the mattress will not reduce pressure to wound areas and can impede wound healing. The facility’s pressure injury prevention policy required following the manufacturer’s instructions for low air loss mattress use, and the operator’s manual directed staff to determine the patient’s weight and set the control knob to that weight setting.