Failure to Maintain Low Air Loss Mattress in Safe Working Condition
Penalty
Summary
The facility failed to ensure that a low air loss mattress was maintained in proper working order for a resident with multiple pressure ulcers and complex medical conditions. The resident, who was cognitively intact and required substantial assistance for mobility, had a care plan that included the use of a low air loss bariatric mattress for pressure reduction due to her high risk for skin breakdown and existing stage 3 pressure ulcers. Despite this, the mattress provided to her was not functioning correctly, as the hose that kept the mattress inflated repeatedly disconnected, causing the mattress to deflate and leaving the resident lying on a hard metal bed frame. Multiple staff members, including a CNA and an LPN, confirmed that the mattress was not staying inflated and that the hose would frequently come off, sometimes requiring makeshift repairs such as duct tape to keep it in place. Family members also reported the issue to facility leadership, providing photographic evidence and written communication about the malfunctioning equipment. The resident herself described experiencing extreme pain, rating it as a 10 out of 10, particularly when the mattress lost air and she was left without adequate pressure relief for her wounds. Interviews with the wound care nurse practitioner and review of the resident's care plan confirmed that the use of a properly functioning low air loss mattress was a necessary intervention for her condition. The facility's own preventive maintenance policy required systematic inspection and timely repair or replacement of essential equipment, but the failure to maintain the mattress in working order resulted in the resident enduring significant pain and inadequate pressure relief for an extended period.