Failure to Ensure Mattress Compatibility with Bedframe Resulting in Resident Discomfort
Penalty
Summary
Facility staff failed to ensure that a resident's mattress was compatible with the bedframe, resulting in the mattress being lopsided and causing discomfort. The resident, who had a diagnosis of low back pain and required partial to moderate assistance with bed mobility, reported ongoing hip pain due to the bed leaning lower at the foot on one side. Visual inspection confirmed that the right side of the mattress at the foot of the bed was significantly lower than the left side, with a measured difference of five inches. The maintenance staff acknowledged attempts to fix the bed but was unable to resolve the issue. The resident expressed that the lopsided mattress was causing pain and reported this to both maintenance and nursing staff. Despite offers to replace the mattress, the resident declined immediate replacement due to concerns about the timing and potential discomfort during the transfer process. The deficiency was identified through observation, resident and staff interviews, and review of facility documentation, which confirmed that the mattress and bedframe were not compatible and that the issue persisted despite staff awareness and attempted interventions.