Failure to Honor Resident Preference for Air Mattress
Penalty
Summary
The facility failed to honor a resident's preference for an air mattress, despite ongoing requests from the resident, her daughter, and her insurance case manager. The resident, who had a history of hemiplegia, obesity, anxiety, generalized weakness, and was at high risk for skin breakdown, was readmitted to the facility and required maximum assistance for mobility. Her care plan identified a potential for skin integrity impairment due to limited mobility and incontinence, and she was being treated for nonhealing moisture-associated skin damage to both ischial areas. Despite these factors and her expressed desire for an air mattress, she was not provided one upon readmission, and her previous air mattress was not located. Interviews revealed that the resident had been requesting an air mattress for over a year, believing it would help prevent further deterioration of her wounds. Her insurance case manager and the insurance company supervisor both stated that they had attempted to facilitate the provision of an air mattress, but were unable to obtain the necessary physician order or clinical documentation from the facility. The case manager reported repeated communication with facility staff, including the social worker and nursing staff, but was told that they did not handle prescriptions and did not provide the required order for insurance submission. Facility staff, including the DON and Regional Nurse, stated that facility protocol required a stage 2 or greater pressure wound for an air mattress to be provided, unless a physician specifically ordered it. The Regional Nurse acknowledged that the resident had previously had an air mattress and that a physician order could override the protocol, but was unsure why the resident did not currently have one. The administrator and wound care nurse were also involved in discussions but did not facilitate the necessary order or documentation, resulting in the resident's continued lack of access to an air mattress despite her ongoing wounds and requests.