Failure to Maintain Functioning Air Mattress for Pressure Relief
Penalty
Summary
A deficiency occurred when a resident with significant cognitive impairment, total dependence for activities of daily living, and at risk for pressure ulcers was not provided with a functioning air mattress as ordered by the physician. The air mattress, intended to provide pressure relief, was observed on multiple occasions to be deflated and not operating because it was plugged into a non-functioning electrical outlet. Despite physician orders and care plan interventions specifying the use of an air mattress and regular monitoring for comfort every shift, the mattress remained non-operational over at least two days of surveyor observation. Documentation indicated that staff were recording daily checks of the air mattress for comfort on the Medication Administration Record, but direct observation by the surveyor revealed the mattress was not inflated and the power was off during these checks. Interviews with nursing staff and the DON confirmed that the mattress was not functioning and that required checks had not been properly performed, resulting in the resident not receiving the prescribed pressure-relieving therapy.