Failure to Ensure Proper Air Mattress Settings and Timely Wound Care
Penalty
Summary
The facility failed to ensure that air mattresses were set at the appropriate settings according to physician orders, resident weight, and manufacturer instructions for multiple residents. In one case, a resident with a stage 3 pressure ulcer was observed lying on an air mattress set at a level inconsistent with the resident's weight, as indicated by the attached instruction card. Nursing staff were unable to confirm or adjust the settings appropriately and did not reference the manufacturer's instructions, despite the presence of clear guidance on the mattress and from the vendor. The facility's policy required nurses to set the correct air mattress setting based on the resident's current weight, but this was not followed. Another resident, who was at risk for pressure ulcers and receiving hospice care, was found on an air mattress set to a firm setting, which was not appropriate for the resident's weight. Nursing staff were unable to explain or adjust the settings and did not know the correct correlation between the resident's weight and the mattress setting. The settings card on the pump was left blank, and staff relied on maintenance or the vendor for guidance rather than following facility policy or physician orders. Documentation indicated that staff signed off on checking the settings every shift, but observations showed the settings remained incorrect over several days. Additionally, the facility failed to initiate timely treatments for a resident with a non-pressure skin condition. Upon readmission from the hospital, the resident had wounds that were not measured or described in the nursing assessment, and no treatment or monitoring orders were put in place for several days. The hospital discharge paperwork included wound care instructions, but these were not implemented by the nursing staff. The Director of Nursing confirmed that it was expected for hospital treatment orders to be followed upon readmission, but could not explain why this was not done. Another resident with malnutrition was found on an air mattress set for a much higher weight than their own, despite staff documentation indicating the setting was checked every shift. The resident and a family member reported the mattress felt excessively hard, and staff admitted to not verifying the settings as required.