Failure to Provide Adequate Supervision and Secure Air Mattresses
Penalty
Summary
The facility failed to provide adequate supervision and ensure that air mattresses were properly secured for two residents. One resident, who had severe cognitive impairment, muscle weakness, and a history of falls, required two-person assistance for transfers and incontinence care, as well as a mechanical lift. During routine care, two staff members were providing incontinence care when the mattress shifted, causing the resident to fall from the bed onto a floor mat, resulting in a small hematoma on the forehead. The nurse aide involved admitted to standing approximately two feet away from the bed, which created a gap that allowed the resident to fall, contrary to his training to close the gap with his body. Additionally, another resident was observed with an air mattress that was not fastened to the bed with the required six straps. The Maintenance Director confirmed that it was common practice for evening or night staff to not secure air mattresses after changing them, which could result in the mattress shifting. Both deficiencies were confirmed by staff interviews and direct observation, indicating a failure to follow facility policy and care plan interventions designed to prevent accidents and ensure resident safety.