Improper Calibration of Pressure-Relieving Air Mattresses for Residents With Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pressure-relieving air mattresses were inflated according to residents’ weights, as required by physician orders and care plan interventions. For one resident with severe cognitive impairment and multiple complex medical conditions, including lymphedema, venous insufficiency, osteoarthritis, rheumatoid arthritis, severe protein-calorie malnutrition, metabolic encephalopathy, and numerous open wounds and pressure injuries (including MASD to both buttocks, unstageable and Stage 3 pressure injuries on the heels, legs, hip, and root), the care plan and orders specified use of an air mattress with monitoring to ensure it was inflated and functioning properly. The resident’s weight was documented as 154.3 lbs, but during observation the air mattress was found set at 180 lbs. The RN interviewed confirmed the mattress setting did not match the resident’s weight and acknowledged that the mattress should be calibrated according to the individual’s weight and that an incorrectly set mattress could contribute to skin breakdown. A second resident, who was moderately cognitively impaired and had diagnoses including type 2 diabetes, prior right tibia fracture, spinal stenosis, polyneuritis, arthropathy, and osteoarthritis, had a documented Stage 3 pressure injury to the right buttock. Skin observation notes by the ADON described the wound measurements and identified it as a pressure injury, and the resident’s care plan included an intervention for an air mattress. The resident’s weight was documented as 196.9 lbs. However, during observation, this resident’s pressure-relieving air mattress was found set at the maximum inflation setting of 380 lbs rather than being adjusted to the resident’s actual weight. In both cases, the facility had established care plan interventions and physician orders requiring that the air mattresses be properly inflated and functioning, with specific monitoring instructions. Despite these directives, surveyor observations and staff interviews confirmed that the mattresses for two residents with existing pressure injuries were not calibrated according to their documented weights. The RN acknowledged in each instance that the settings were incorrect and that the mattresses should have been set based on the residents’ weights, and further confirmed that incorrect inflation could contribute to skin breakdown.
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