Improper Installation of Medical Equipment and Unsanitary Wheelchair
Penalty
Summary
A deficiency occurred when a low air loss mattress, intended to prevent and treat pressure injuries, was improperly installed for a resident with moderately impaired cognition. The air hose connectors were positioned at the head of the bed and left on the floor, contrary to manufacturer instructions that specify placement at the foot of the bed. The resident reported being struck in the head by the machine multiple times over a two-week period and stated that a CNA was informed but did not correct the setup. Observations by the Maintenance Director and a Licensed Vocational Nurse confirmed the improper installation and location of the air hose connectors. Additionally, the same resident was provided with a wheelchair that had a cracked and peeling right arm rest and a left arm rest covered in duct tape. The resident stated the wheelchair was received in this condition. The Maintenance Director confirmed the damage and was unable to verify if the arm rests could be sanitized. A Licensed Vocational Nurse stated that cracked and peeling arm rests should be replaced, as they cannot be properly sanitized. The facility's infection prevention and control policy requires maintaining a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases.