Failure to Provide Timely Replacement of Defective Mattress
Penalty
Summary
A deficiency occurred when a resident was left to lie on a sunken, deflated mattress despite having reported the issue to both the Maintenance Director and an LPN. The resident, who is oriented and able to communicate needs, stated that he had informed the Maintenance Director about the mattress, who confirmed the mattress was deflated on one side and promised replacement. The resident also told the LPN about the problem, but the LPN did not document the concern or report it in the maintenance log, as the resident indicated he had already notified maintenance and was waiting for resolution. The Director of Nursing was unaware of the issue and stated that staff are expected to document such complaints in the facility work order system, which is checked daily by maintenance. However, no record of the mattress concern was found in the facility's grievance binder or work order logs. Additionally, the facility administrator stated that if a concern is reported directly to maintenance, it is not expected to be entered into the maintenance logbook, but the resident's needs should be met as soon as possible depending on the situation. The facility was unable to provide a policy regarding furniture or equipment. The lack of documentation and follow-through resulted in the resident continuing to use an uncomfortable, sunken mattress for an extended period.