Improper Mattress Positioning Creates Accident Hazard
Penalty
Summary
The facility failed to ensure the resident environment was free of potential accident hazards for a resident with significant cognitive and physical impairments, including Alzheimer's disease, dementia, schizoaffective disorder, repeated falls, and dependence on staff for transfers and mobility. The resident's care plan included interventions to prevent sliding out of a wheelchair and to encourage non-skid footwear, but did not address measures to prevent rolling out of bed. Observations revealed that staff placed a solid triangular-shaped cushion between the mattress and the bed frame, causing the mattress to tilt toward the wall and creating a two-to-three-inch gap between the bed and the wall. This setup made it possible for the resident to slide into the gap and become trapped, especially given her inability to free herself due to her condition. Interviews with staff indicated a lack of understanding regarding the purpose and safety of the cushion placement, with one CNA stating it was used to prevent the resident from rolling out of bed, while the LPN was unaware of its purpose. The DON was not aware that staff were using the cushion in this manner and stated that it should not be done. Review of the bed manufacturer's manual indicated that the mattress should be snug against all mattress retainers and warned that improper installation of components could lead to entrapment issues. The facility's failure to identify and address this hazardous setup resulted in a deficiency related to accident prevention and environmental safety.