Failure to Maintain Inflated Pressure Reducing Mattress for At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for skin breakdown was left on a deflated air-loss pressure reducing mattress for over eight hours. The facility's policy required the use of a specialized mattress for residents at risk of pressure ulcers, and the resident's care plan included an intervention for a pressure reduction mattress. Observations revealed that the mattress had a low air pressure warning light activated, and the bed frame was palpable when pressure was applied, indicating the mattress was not properly inflated. The resident reported hearing air escaping from the mattress and informed staff, who responded only by confirming the mattress was plugged in, without physically checking the mattress's inflation. Further investigation found that a nurse on the night shift observed the low air pressure warning and later determined that the CPR function on the mattress had been activated, causing it to deflate. The Assistant Director of Nursing confirmed that the resident remained on the deflated mattress for an extended period. The resident had a history of hemiplegia, moderate cognitive impairment, and was at risk for pressure ulcers due to incontinence, debility, and comorbidities. The failure to ensure the mattress was properly inflated and to respond appropriately to the resident's report led to the deficiency.