Failure to Timely Accommodate Resident Mattress Request
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident had a comfortable mattress, as required to reasonably accommodate the needs and preferences of each resident. The resident, a male with a history of cerebral infarction, pain, insomnia, type 2 diabetes, hemiplegia, and hemiparesis, was at risk for developing pressure ulcers and required setup assistance for activities of daily living. The resident reported that he had requested a new mattress at the beginning of the previous week due to discomfort and the mattress being thin, but had not received one at the time of the initial observation. Staff interviews revealed that the resident had complained multiple times about the mattress, and it was noted that the mattress may have developed a hole due to previous weight changes. However, there was confusion among staff regarding whether a maintenance request had been submitted, with some staff stating they may have verbally informed maintenance or believed someone else had submitted the request. The maintenance staff confirmed that the first formal request was received and addressed on a specific date, and the mattress was found to have an indentation. The facility did not have a process for scheduled mattress inspections, and maintenance issues were generally reported by staff, residents, or family members either verbally or through a maintenance request book. The Director of Nursing and other staff acknowledged the importance of a comfortable mattress for resident well-being, but there was no evidence of proactive monitoring or timely response to the resident's initial complaint, resulting in a delay in addressing the resident's discomfort.