Failure to Ensure Proper Inflation of Specialized Air Mattress
Penalty
Summary
A deficiency occurred when a resident with reduced mobility, legal blindness, type 2 diabetes mellitus, and morbid obesity was found sleeping on a deflated alternating air mattress. The resident's medical records and provider orders indicated the need for a specialty alternating air mattress to prevent or treat pressure injuries. The care plan also documented the use of this therapeutic mattress. However, during an observation, the mattress was found to be off, deflated, and without any power lights while the resident was in bed. Interviews with facility staff confirmed that the mattress was not properly inflated. An LPN acknowledged that the deflated mattress could cause entrapment or additional pressure wounds and stated that all nursing staff were responsible for checking resident care equipment. The DON also stated that it was her expectation for nursing staff to check equipment during daily rounds and that malfunctioning equipment could lead to negative outcomes for residents. The failure to ensure the resident's air mattress was properly inflated constituted the deficiency.