Failure to Follow Safety Protocols During Resident Care on Low Air Loss Mattress
Penalty
Summary
Certified nurse assistant (CNA) 5 failed to follow established safety protocols while providing care to a resident who was dependent on staff for all mobility and had moderately impaired cognition. The resident, who had muscle weakness and encephalopathy, was ordered to use a low air loss mattress (LALM) for skin management. During a routine care activity, CNA 5 changed the resident on the LALM without placing the mattress in static mode and without the required two-person assistance. As a result, the resident rolled off the bed and fell to the floor. Interviews and record reviews confirmed that facility policy and in-service training required the LALM to be set to static mode and a two-person assist to be used when changing immobile residents on this type of mattress. CNA 5 admitted to not being aware of these requirements at the time of the incident. The incident was corroborated by progress notes and staff interviews, which highlighted the deviation from established procedures intended to prevent such accidents.