Resident Left Lying Directly on Plastic Mattress Packaging
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by allowing a resident to lie directly on the sealed plastic packaging of a new mattress. The resident was an elderly female with a history of cerebral infarction sequelae, glaucoma, congestive heart failure, and type 2 diabetes. Her MDS showed moderate cognitive impairment (BIMS score of 8), total incontinence of bowel and bladder, and dependence on staff for toileting, showers, and transfers. Her care plan identified an ADL self-care deficit related to debility and required extensive assistance by two staff for bed mobility and weekly skin inspections. A recent reentry skin assessment documented only bruising from an IV and no pressure wounds. On the survey date, observation revealed the resident lying in bed on top of the protective plastic packaging of a brand-new mattress, with her exposed back and bare calves in direct contact with the plastic. The resident reported hearing a sound when she moved and stated she did not know how long she had been on the plastic but that her legs were hurting, then requested assistance to move her legs. When RN A entered the room and repositioned the resident’s legs, she observed that the resident’s bare calves had been lying flat on the plastic. RN A stated she did not know who had placed the resident on the new mattress without removing the plastic or how long the resident had been on it, and acknowledged that the resident’s skin was directly on the plastic and that this was not a homelike environment. Multiple staff interviews confirmed that the plastic packaging had not been removed prior to the resident being placed on the mattress and that expected practices were not followed. CNA C reported the resident had been back from the hospital for about a week and stated she did not know why the person who put the resident on the new mattress did not remove the packaging or extend the bottom sheet, noting that the material under the resident was the actual packaging, not a specialized mattress surface. CNA D stated he had been assigned to the resident, noticed at the start of his shift that the mattress still had plastic packaging, and assumed it might be a specialized mattress from a vendor and did not verify this with a nurse. The MDS nurse, DON, and Administrator each stated that the expectation was that plastic packaging would be removed and the bed made with appropriate linens before a resident was placed in bed, and acknowledged that in this case the resident had been left lying directly on the non-breathable plastic packaging of the new mattress.
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