Improper Use of Low Air Loss Mattress for Resident With Stage III Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper use of a low air loss mattress (LALM) for a resident with a sacrococcygeal stage III pressure injury. The resident was admitted with osteoarthritis of the left knee, a left artificial knee joint, and a stage III sacral pressure ulcer, and had intact cognition per the MDS. The physician’s orders and the care plan included use of a LALM with settings based on the resident’s comfort and/or weight, and monitoring for proper settings and functionality, with the goal that the resident would not have further skin breakdown by monitoring the LALM in the correct setting. During observation, the resident was found lying on a LALM while wearing an incontinence brief, with a flat sheet and a cloth incontinence linen pad underneath, resulting in four layers of linen between the resident and the mattress. During interviews, CNA staff stated that the resident was on the LALM due to an open wound on the resident’s bottom and acknowledged that there were four layers of linen under the resident, while indicating there should only be one layer between the resident’s skin and the LALM. The DSD stated that for residents on a LALM, only flat sheets should be used and staff should use either disposable pads or an incontinence brief, but not both at the same time, and that there should be no more than two layers of linen between the bed and the resident for the LALM to function appropriately. The DON stated that LALMs are used primarily for skin management and that using more than two layers of linen would defeat the purpose of the LALM and delay wound healing. The DON also stated the facility did not have a policy and procedure specific to LALM use, and the existing pressure ulcer/skin breakdown protocol only generally referenced physician orders for pressure reduction surfaces without detailing LALM application or linen use.
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