Failure to Monitor Air Mattress Results in Pressure Ulcer Care Deficiency
Penalty
Summary
The facility failed to ensure that a resident with multiple medical conditions, including heart disease, respiratory failure, systemic infections, unstable blood sugar, and bilateral leg amputations, received necessary treatment and services consistent with professional standards for pressure ulcer management. The resident, who was bedbound and had two Stage 4 pressure ulcers, was assessed to require an air mattress as a pressure-relieving intervention. However, there was no routine monitoring procedure established to ensure the air mattress was functioning properly. The care plan and safety device assessment indicated the need for the air mattress, but there was no physician order or documentation directing staff to monitor the device until after an incident occurred. On one occasion, the resident's representative found the air mattress deflated, with the resident lying on the metal bars of the bed. Staff who responded did not initially notice the malfunction. The following day, the wound nurse observed worsening redness on the resident's back, prompting the representative to request hospital evaluation. Interviews with staff confirmed the air mattress was unplugged and that there was no record of when it was last checked. The Director of Nursing acknowledged that staff were responsible for checking the air mattress each shift, but no monitoring order was in place prior to the incident.