Failure to Ensure Proper Use and Monitoring of Air Mattress
Penalty
Summary
A deficiency was identified when a resident, who was totally dependent on staff for activities of daily living and had no current or recent pressure ulcers, was found in bed with an air mattress that was unplugged and not inflated. The air mattress was later plugged in by a nurse and observed to be set at 240 lbs, despite the resident's most recent recorded weight being 115.8 lbs. The medical record only contained an order for a pressure reducing mattress, not specifically for an air mattress, and there was no order or documentation for monitoring the use of the air mattress. Further review revealed that staff were unaware of how the air mattress was assigned to the resident, and the unit nurse manager was not informed that the bed had an air mattress. The air mattress was used without an appropriate physician order, without monitoring instructions, and was set at an incorrect weight setting. The DON confirmed that air mattresses were typically reserved for residents with Stage 3 or 4 pressure ulcers and that this resident did not require one. The lack of an order and monitoring for the air mattress, as well as improper setup, constituted a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.