Failure to Complete Air Mattress Safety Assessments
Penalty
Summary
The facility failed to complete safety assessments for three residents who were provided with air mattresses. For each of these residents, clinical record reviews and observations confirmed that there was no documented evidence that an assessment for potential safety hazards related to the use of an air mattress was conducted prior to its placement on the resident's bed. This was further confirmed through interviews with the Director of Nursing, who acknowledged that safety assessments had not been completed for these residents before the air mattresses were put in use. The residents involved had significant medical conditions and care needs. One resident was cognitively impaired, required assistance with daily care, had a Stage 3 pressure ulcer, and diagnoses including dementia and Parkinson's Disease. Another resident was cognitively impaired, required extensive assistance, and had diagnoses of Parkinson's, stroke, and sarcopenia. The third resident was cognitively intact but required extensive assistance and had a history of hip fracture and contractures. Despite these vulnerabilities, the facility did not assess the safety of air mattress use for these individuals as required.