Failure to Complete Air Mattress Safety Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible by not completing air mattress safety assessments for two residents. According to the facility's policy, support surfaces such as air mattresses are to be used in accordance with manufacturer recommendations, including consideration of contraindications, and should be subject to scheduled inspection and replacement. However, for one resident with dementia who required staff assistance for daily care, and another resident who was cognitively intact and had a pressure ulcer, there was no documented evidence that an assessment for potential safety hazards was completed prior to the placement of air mattresses on their beds. Observations confirmed that both residents were in bed with air mattresses in place, and interviews with the Director of Nursing verified that no specific safety assessments had been conducted for either resident regarding the use of these mattresses. Physician's orders for both residents included the use of air mattresses, but the lack of documented safety assessments constituted a failure to follow facility policy and regulatory requirements.