Failure to Ensure Proper Functioning of Ordered Air Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper functioning of an ordered air pressure mattress for a resident assessed as at risk for pressure ulcer development. The resident’s MDS documented diagnoses of malnutrition and Inclusion Body Myositis, moderate cognitive impairment (BIMS score 10), total dependence for all ADLs including bed mobility, and constant bowel and bladder incontinence, with recent weight loss and a current weight of 93 pounds. The care plan identified the resident as at risk for pressure ulcers related to weakness and reduced mobility, with a goal for skin to remain intact, and included use of an air pressure mattress as a specific intervention. Surveyor observations over multiple days showed repeated problems with the air mattress not being powered on and/or not functioning properly. On one occasion, the resident was observed in bed with the air mattress pump not on; on several other occasions, the pump was on but the low-pressure light was illuminated, and on multiple subsequent observations the air mattress was again off while the resident was in bed. A medication aide confirmed that the air mattress was not on and should have been. The wound nurse confirmed the low-pressure light was on and stated they would need to refer to the owner’s manual to determine its meaning. The ADON confirmed the mattress was being replaced and provided manufacturer information indicating that if the low-pressure light remained on for longer than 30 minutes, the mattress should be serviced.
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