Failure to Complete Safety Assessments for Siderails and Air Mattresses
Penalty
Summary
The facility failed to complete required safety assessments for residents using siderails and air mattresses. For one resident who was cognitively intact and required assistance with daily care due to an infection of a right knee prosthesis, the facility's siderail/assist bar evaluation was not fully completed, specifically omitting the section to determine if siderails or assist bars were indicated. Despite this incomplete assessment, observations confirmed that the resident was using bilateral upper siderails during multiple surveyor visits. The Director of Nursing confirmed that the last two assessments for this resident were not fully completed to identify the need for siderails. Additionally, two other residents who were dependent on staff for personal care and had orders and care plans for the use of air mattresses did not have documented safety assessments for the air mattresses prior to their use. One of these residents was cognitively intact with a diagnosis of chronic deep vein thrombosis, and the other was cognitively impaired with cerebral palsy and at risk for pressure sores. Observations confirmed that both residents were using air mattresses, but there was no evidence of safety assessments being completed. The Director of Nursing acknowledged that air mattress safety assessments were not completed for residents using air mattresses at the time of the survey.