Choosing the Right Support Surface in Long-Term Care
Can the wrong mattress cause a pressure injury? Support surfaces play a major role in preventing painful and dangerous wounds. When nursing homes cut corners, residents suffer. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Michelle Swanger to discuss how support surfaces should be selected and used to prevent pressure injuries.
Swanger:
Also you wanna look at their weights. What is their BMI? Some of those surfaces all are only rated for a certain weight. So you wanna make sure that you’ve either communicated with the vendor or your manufacturer to make sure, Hey, we’ve got a resident with a particularly high BMI and this is what their body weight is. Is this surface still appropriate for them?
Intro
Schenk:
Hey out there. Welcome back to the Nursing Home Abuse podcast. My name is Rob. I’ll be your host for this episode. Today we are having a conversation about. The types of pressure relieving support surfaces that you would find in long-term care, whether you’re sitting in a wheelchair or laying in a bed, and how they function and what their role is and.
I could tell you that we’re not having that conversation alone. It’s too scientific. So it’s, you definitely don’t want me to jot on about it. So we have the fantastic Michelle Wanger on the show to walk us through that process. Michelle has been a legal nurse consultant focusing on nursing home and assisted living facility cases for the last five years. She is a subject matter expert in the MDS assessment and nursing home regulations. She has worked in nursing homes for much of her career holding roles as a nursing assistant, MDS coordinator, nursing supervisor, director of nursing, and corporate director of clinical reimbursement and documentation.
So in other words, she’s extremely highly qualified to be with us today, and we’re so happy that she’s here. Michelle, welcome to the show.
Swanger:
Great to be here.
What are pressure relieving surfaces, and how do they work?
Schenk:
I typically start off. The guest interviews with the softball question and your softball question is, what exactly is a support surface with respect to pressure injury prevention?
Swanger:
So support services are usually designed to relieve or reduce pressure on the body’s tissues. And they usually do that by redistributing that pressure across a larger part of the body or varying the pressure.
Long-term outcomes related to skin breakdown are discussed on the impact of preventive health measures in elderly populations in institutional care settings.
What types of pressure relieving surfaces are commonly used?
Schenk:
And so if we’re talking about, we can, I guess we can get to wheelchairs in a second, but if we’re talking about a bed, okay, what does it typically look like? Is it look like I’m picturing a mattress, or is it like a pillow? Are there different kinds?
Swanger:
Yeah, so there’s different categories of support surfaces. Most generally when we’re talking about a nursing home, the majority of nursing homes now have their standard mattress which would be a pressure relieving mattress.
Doesn’t completely reduce the pressure, but relieve some of the pressure. So a gel. Mattress or a foam or a combination type of mattress. And then there’s other categories that are more intense depending on what that resident’s risk level is or if they have any skin breakdown.
Recent findings emphasize systemic contributors on the impact of preventive health measures in elderly populations affecting wound prevention and healing.
Schenk:
So I’ve heard the term low air mattress for a long time. Can you walk me through you, you lay a resident down on a low air mattress, what does it look like? What’s going on?
Swanger:
So a low air loss mattress has a number of cells in it. And what happens is that, that mattress will inflate and deflate in the sequence. So it helps to reduce the pressure ongoing across the surface area of the body that’s touching that mattress.
Earlier clinical observations remain relevant on the impact of preventive health measures in elderly populations when evaluating preventability arguments.
How can the right support surface help prevent pressure injuries?
Schenk:
So it’s not a matter of it being static, like it is, there’s something mechanical going on that is moving well, for lack of a better term, moving and I’m using my little finger air quotes moving the mattress around to redistribute the weight.
Swanger:
Correct. Correct.
Schenk:
Okay. So tell me then about how do we or what does a surface, a support surface look like on a wheelchair? Is it the same? Is it, does it also move around?
Swanger:
So they do make cushions. There’s a particular brand of cushion called a roho cushion, which is individual air pockets. So as the resident moves in that chair, those pockets will increase or decrease. They also frequently you’ll see just a gel cushion used, which again, just helps to re alleviate some of that pressure redistributed across the part of the body that’s touching that surface, so that not as many options for a resident who’s gonna be in a wheelchair if they’re at a very severe risk or high risk or have skin breakdown.
Oftentimes you’ll see the recommendation from a consultant to reduce, or the number of hours that they’re sitting upright in a chair.
This academic work explores care delivery challenges on the impact of preventive health measures in elderly populations tied to pressure injury development.
Schenk:
So in your experience, and again, every nursing home is different, but would it be the common practice that you would only find low airflow mattresses and that’s their support surface of choice?
Or is it like you walk into a room and there’s a low air mattress and or the next thing, or the next thing and then they just pull it out according to the needs of the resident.
Swanger:
I think most nursing homes work with certain vendors, so it’s what their vendor can provide for them. Or if they work with a con wound care consultant group, probably what they would most often recommend.
If it’s a facility that has a lot of wounds or specializes in wounds, yeah, you’ll see different types of surfaces for different residents. Anywhere from that. Standard, maybe gel mattress all the way up to an air fluidized bed where they’re essentially floating on that surface.
Broader public-health implications are examined on the impact of preventive health measures in elderly populations related to preventable harm in older adults.
Schenk:
Oh, cool. Can you walk us through the Cadillac of support surfaces that you just mentioned and just kind, we’ll work backwards and of what makes one a Cadillac in one more like my old F two 50.
Swanger:
Sure. The air fluid ice bed that I referenced just a minute ago, essentially replaces the bed. So the resident’s bed would leave the room. This bed comes in, it’s a powered bed that you plug in and it generates warm air that flows across the mattress and almost levitates the resident.
They’re not quite levitating, but it just is a constant flow of air, so it keeps the skin dry, which is really important if they’ve got active wounds because moisture does not help wound healing. We want the skin to be nice and dry, and then it. Relieves all the pressure. So lots of these surfaces can reduce the pressure but not completely relieve pressure.
An air fluidized bed, which is the Cadillac of surfaces, would completely relieve the pressure on that resident.
Healing timelines vary widely, as explained in our guide on how long it takes pressure ulcers to heal.
Schenk:
And is there a next step down in your opinion?
Swanger:
Sure. So then we also see not quite as often, but there are beds made that are called a tilt and turn bed where it will move right to left and up and down to redistribute that pressure on the resident again, doesn’t completely relieve the pressure, but does a much better job than.
What the next step would be, which is your low air loss mattress or your alternating pressure mattresses where they’re alternating that pressure, but the pressure’s still there.
Families often ask about accountability, which is addressed in whether you can sue a nursing home for bed sores.
Schenk:
And then I would imagine the next step down would be what you’ve described at the top of the show, which would’ve been a low airflow mattress. That would kinda be the next thing.
Swanger:
Correct.
How should nursing homes decide which pressure relieving surfaces to use?
Schenk:
Okay, so let’s pretend that we’re in and maybe this doesn’t exist in the real world, but let’s pretend that we are in a facility that has the gamut. You got the Cadillac all the way down to the 2005 FF two 50.
What would, in your mind, what would, what is the checklist for which resident would be a candidate for any individual? One, like what is a particular Brayden scale score? Is it just this person’s high risk or they’re going over here versus that? Is there a checklist in other words?
Swanger:
Sure. Yeah, so you would start with whatever your risk assessment tool is, whether it’s a Braden and Norton, maybe you have some other standardized tool that you’re using, but you wanna start looking there. You wanna look at the score, but not just that number. So you wanna look, if you’ve got a resident who’s a 10 to 12, which is a high risk, somewhere in there, why are they a 10 to 12?
If it’s somebody who’s scoring low because they don’t eat well, and maybe they’re, incontinent a lot, you can solve those issues in other ways besides a support surface. So they may not be, even though they’re a high risk, they may not be the candidate for that air fluid ice bed. On the other hand, you may have a resident who you know you wanna look at.
Facilities are expected to follow basic standards, including what a nursing home can do to prevent bedsores.
Do they have active pressure ulcers now, or have, do they have recently healed pressure ulcers or a significant history of. Also you wanna look at their weights. What is their BMI? Some of those surfaces are only rated for certain weights. So you wanna make sure that you’ve either communicated with the vendor or your manufacturer to make sure, Hey, we’ve got a resident with a particularly high BMI and this is what their body weight is.
Is this surface still appropriate for them? And on the other side. Also those residents that have a low BMI, you wanna look at probably a higher support surface for them, even if they don’t have skin breakdown because they’ve got less fatty tissue to pad those bony promises.
Visual documentation matters, which is why we provide bed sore stages with pictures for families and professionals.
Schenk:
Interesting. So I guess I have never, I guess I never considered manufacturer specifications.
And that makes complete sense if someone exceeds a certain weight. They’re not gonna achieve the benefit of what the surface is designed for. Okay. So it seems to me that part of the checklist aside from maybe, what the manufacturer, maybe the person’s too tall or whatever, right?
Other than that it looks like the critical components are mobility. And previous injuries. So in other words, a person is more likely to be a candidate for the Cadillac if they’re unable to move themselves at all and perhaps are cognitively impaired or have sensory perception issues versus it’s really nutrition.
It’s really you, maybe non-compliance or something that’s making them a high risk or whatever. I see that’s interesting. Okay, so now we’ve assigned or we have a kind of an understanding as who’s going on onto what, l kind of the same thing, but for someone that is in a wheelchair, and I get that no matter what, you wanna limit somebody’s time in a wheelchair because that’s applying the maximum pressure over the smallest amount of tissue.
But walk us through, I guess it seems to me that it’d be the case that if you’ve got the best stuff, it’s just going right to you. There’s, there wouldn’t be an analysis or is there.
Swanger:
There is, you wanna make sure they’re you wanna, again, look at their risk factors.
Is this a resident who can get up out of the chair on their own and move around, what is their mobility? You also wanna partner with your therapy department, your physical therapy department. Is this gonna keep their body in the best alignment? There might be some residents who, if you’re putting them on a gel cushion.
Best practices and prevention strategies are discussed in Preventing Pressure Ulcers in Nursing Homes.
They’re gonna slide. So they need something to help keep them into the, in the chair in position better. So working again with your therapy professionals to make sure that hey, we need a support surface to help relieve pressure. But we also wanna make sure the resident is safe and they’re in good alignment in this chair, so working with them as well.
Equipment selection and misuse are covered in Support Surfaces for Treating Pressure Ulcers.
Schenk:
So here’s the $64,000 question for anybody of a certain age that understands that reference. What opinion do you have, if any? What or what, lemme say this. What typically is the opinion perhaps of the N-P-I-A-P of, even if you have a Cadillac surface support surface, does that truly replace the need to turn reposition?
Swanger:
So in those air fluidized beds, it pretty much does replace you should be going in there and one of the things I probably didn’t mention about any of these powered devices, they should be checked every shift because they get. Bumped, they have settings, they have numbers that have to be set. So you wanna make sure you’re recording where the, what those settings should be because they’re different for every resident based on their weight, based on their body type.
Documentation and classification issues are analyzed in Episode 199: What Role Does Staging Play in Pressure Injury Care?.
So you wanna make sure the setting is correct. It didn’t come unplugged from the wall and now they’re laying in the case of the Air Fluidized bed. When that bed becomes unplugged, they’re laying on hard sand. It’s a sand base on that bed. And not a good situation. So even in that air fluidized bed, you wanna go in, you wanna make sure you’re still checking those bony prominences.
You don’t necessarily have to reposition the resident, but you still should be checking their heels. They’re sacrum, their elbows, the back of their head. They’re shoulder blades because something may have happened in the eight hours since the last person was in, or the four hours or whatever. How often or how frequently they’re checking to make sure that nothing is happening. Maybe the bed malfunctioned, we weren’t aware.
Common myths and misconceptions are addressed in Episode 201: Unpacking the Truths About Pressure Injuries in Nursing Homes.
Schenk:
Typically in your experience, is that the CNA doing that or the nurse? And if so, how does the CNA know how to, know what it sounds like if it’s not plugged in, versus if it’s plugged in and what the settings should be?
Swanger:
So the nurse should be checking the settings every shift. So each shift, a nurse should go in and check the settings. They should also be Ed educating their frontline caregivers, those nursing assistants, to say, Hey, if you have all of these power devices, you can hear them when you walk in, you know they’re working.
You can hear the air moving and the sound that it makes. So if you don’t hear that or you don’t see that moving when you’re providing care, come get me and let me know. That’s the extent that we would expect a nursing assistant to just notify the nurse that, Hey, I don’t think this is working right.
Defense arguments and medical complexity are examined in Episode 205: Co-Morbidities, Unavoidability, and Pressure Injuries.
’cause I don’t hear anything going on or. A lot of them have a little box that hang at the bottom of the bed. I walked past the box, and the numbers were just blinking. Making sure they’re educated to know this is a really important surface for this resident and we wanna make sure they’re getting the most benefit from that. So if you feel in some way it’s not working, please come get me and I’ll check it.
Schenk:
It almost seems more critical to check if they’re on that type of mattress, because if it does go out. They’re sitting on es essentially, as you mentioned, like flat sand, which is to me, I guess maybe more dangerous. I don’t know.
Swanger:
That seems to be the case. It is. Yeah.
Critical staffing and assessment metrics are explained in Episode 208: Top Three Crucial Data Points from the MDS About Pressure Injuries.
Schenk:
Michelle, we very much appreciate you coming on the show and sharing your knowledge with us today.
Swanger:
Thank you. I’ve enjoyed it.
Schenk:
Folks, I hope that you found this episode educational. If you have an idea for a topic that you would like for me to discuss, please let me know.
If you have an idea for someone that you would like for me to talk to as a guest, let me know that as well. New episodes of their podcast come out every single Monday. For now be sure to enter the contest to win the coffee mug. Still, there are two gigantic boxes of these coffee mugs that are taking up way, much, way too much space at the house.
So please, by all means. Comment, enter to win. You’ll win, I promise you. And with that folks. We’ll see you next time.
Thanks for tuning in to the Nursing Home Abuse podcast. Nothing said on this podcast either by the host or the guest, should be construed as legal or medical advice, nor is intended to create an attorney-client relationship between the host or their guest and the listener. New episodes for now are available every other Monday on Spotify, Apple Podcasts, or on your favorite podcast app, as well as on YouTube and our website, nursing home abuse podcast.com.
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Michelle Swanger’s Contact Information: