Failure to Assess Air Mattress Safety and Provide Wheelchair Leg Rests
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards by not completing air mattress safety assessments for multiple residents prior to the use of air mattresses. Specifically, for eleven residents, including those with cognitive impairments, pressure ulcers, and other significant medical conditions, there was no documented evidence that an assessment was performed to identify potential safety hazards associated with the use of air mattresses. Physician orders and care plans indicated the use of air mattresses for pressure relief and skin integrity, but the required safety assessments were not completed before these devices were put in place. Observations confirmed that these residents were using air mattresses, and interviews with facility staff, including the Nursing Home Administrator, verified that no bed safety assessments had been conducted prior to the placement of the air mattresses. The residents involved had varying degrees of cognitive impairment and physical dependency, with some being at risk for falls, having pressure ulcers, or requiring bariatric equipment. Despite these risks, the facility did not document any evaluation of the safety of air mattress use for these individuals. Additionally, the facility failed to provide appropriate assistance devices during wheelchair transport for one resident. An LPN was observed pushing a resident in a wheelchair without leg rests, resulting in the resident's feet dragging on the floor. The LPN stated that leg rests were not used because the resident could self-propel, but acknowledged that they were not in place during transport. The Nursing Home Administrator confirmed that leg rests should have been used if the resident's feet were dragging, but that they were not routinely kept on wheelchairs for residents who could self-propel.