Failure to Ensure Proper Air Mattress Functionality for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for two residents. The first resident, who was admitted with a pressure ulcer and had a high risk for developing additional ulcers, was found to have an air mattress weight setting that did not correspond with their actual weight. This discrepancy was observed during a survey, and the Wound Care Registered Nurse acknowledged the mistake, stating that the correct weight setting is crucial for wound healing. The Director of Nursing Services confirmed that it is the responsibility of the nursing staff to ensure the air mattress settings are correct. The second resident, who was at risk for pressure ulcer development and acquired an unstageable pressure ulcer while in the facility, was found lying on an air mattress that was not plugged into a power outlet, rendering it non-functional. This was discovered during an observation, and the issue was rectified by plugging the mattress into the outlet. The Wound Care Registered Nurse and the Director of Nursing Services both stated that all nursing staff, including Certified Nursing Assistants, are responsible for ensuring that the air mattress is plugged in and functioning properly.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action Despite routine checks of functionality and of the adjustment knob by nursing staff, the air mattress setting was inadvertently not aligned with the resident’s current weight. Resident #123: The air mattress was immediately adjusted to match the resident’s actual weight of 95.6 lbs. Resident #50: The air mattress was immediately plugged into the power outlet and confirmed to be fully functional. Staff involved were re-inserviced on their responsibilities regarding equipment operation. Care plan and treatment orders were reviewed and reinforced. II. Identification of other residents A facility-wide audit of all residents with physician orders [REDACTED]. The audit included verification of: - Current weight settings vs. resident weight. - Functionality (power connection) of each air mattress. - Staff awareness regarding equipment monitoring. III. Systemic Changes A mandatory in-service training will be conducted for all licensed nurses and CNAs on: - Importance of matching air mattress settings to resident weight. - Daily functionality checks (including ensuring the mattress is plugged in and operating properly). - Documentation and escalation protocols if discrepancies are noted. The policy on Air Mattress was reviewed and found to be appropriate. A modification has been made whereby an Air Mattress Check q shift has been added to the Treatment Accountability Record (TAR), requiring a nurse signature. IV. QA Monitoring An audit tool was developed for all residents on air mattresses for: - Correct weight settings - Proper power/functionality - Accuracy of related documentation Audit results will be submitted to the Director of Nursing weekly. Any non-compliance identified will be addressed with immediate re-education and progressive disciplinary action if warranted. Audit frequency will be weekly for 1 month, monthly for 2 months until 100% compliance. Audit findings will be compiled, analyzed and brought to the QAPI Committee meeting for review and assessed for continuance, based on compliance and incidence of negative findings. Person Responsible: Wound Care Coordinator