Improper Low Air Loss Mattress Setting for Resident With Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain appropriate pressure-reducing measures for a resident with an existing pressure injury. The resident was admitted with multiple diagnoses including left-sided hemiplegia, history of stroke, type 2 diabetes, depression, congestive heart failure, and hypertension, and weighed 168.3 pounds according to a weight listing. The physician’s order directed specific wound care to the buttocks, including cleansing with normal saline, patting dry, applying calcium alginate, and covering with a dry clean dressing. A progress note documented that the hospice nurse was updated on open areas to the buttock and that an air mattress had been ordered. During observation, the resident was found in bed on a low air loss mattress, but the mattress weight control knob was set at the 600-pound setting, despite the resident’s documented weight of 168.3 pounds. In an interview, the facility wound nurse confirmed that the low air loss mattress was set at 600 pounds and acknowledged that the mattress is supposed to be set according to the resident’s weight, and that once the mattress was inflated, the setting had not been adjusted to the resident’s actual weight. Manufacturer guidelines for the low air loss mattress indicated that the pressure dial is adjustable to the patient’s weight and comfort, and the facility’s skin policy stated that preventive measures would be implemented according to the resident’s assessed risk level and risk factors for skin integrity impairment.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.