Resident Placed on Floor Mattress Without Bed Frame or Bedrails
Penalty
Summary
A deficiency occurred when a resident's mattress was placed directly on the floor without a bed frame or bedrails, contrary to the resident's care plan, which specified the use of a high-low bed in the lowest position. The resident, a female with metabolic encephalopathy, dysphagia, and a recent colostomy, was completely dependent on staff for all self-care and mobility, and had a surgical wound. Staff interviews revealed that transferring the resident from a floor-level mattress was uncomfortable and unsafe, especially when using a mechanical lift, and that this arrangement restricted staff's ability to provide appropriate care. The facility had high-low beds available that could be positioned close to the ground, but these were not utilized for this resident. Further review indicated that the facility had not provided training to staff on care practices for individuals with intellectual disabilities or on the use of floor-level mattress placement. The Director of Nursing acknowledged that alternative safety interventions were available and that the resident may have felt she was not treated equally to other residents. Facility policy required that all residents be cared for in a manner that promotes well-being, self-worth, and dignity, and that cognitively impaired residents be treated with sensitivity. The failure to provide a safe, clean, and homelike environment as outlined in the care plan led to the deficiency.