Failure to Ensure Ordered Low Air Loss Mattress Was Functioning for At-Risk Resident
Penalty
Summary
A resident identified as R54, who was assessed as at risk for pressure ulcers on a quarterly MDS and had fragile skin, had a physician order dated 6/5/25 for an alternating low air loss mattress with placement and function to be checked every shift. During multiple surveyor observations on 9/22/25, R54 was seen asleep in bed on her left side with the low air loss device not turned on. On 9/23/25, an observation with an LPN (E43) showed that the low air loss mattress device was not plugged into the wall outlet behind the head of the bed; once it was plugged in, the device powered on and displayed a green light. R54 reported that she does not get out of bed. Review of the September 2025 eTAR showed that for the period covering 9/22/25 into 9/23/25, the nurse on the 7:00 AM to 3:00 PM shift (E44, LPN) did not sign off the ordered preventative treatment, leaving it blank, while the 3:00 PM to 11:00 PM nurse (E45, LPN) and the 11:00 PM to 7:00 AM nurse (E39, LPN) both signed off the treatment as completed. Despite these electronic records indicating completion on two shifts, surveyor observations and the subsequent check with E43 confirmed that the low air loss mattress was not plugged in or functioning as ordered. The facility therefore failed to ensure that this resident at risk for pressure ulcers received the physician-ordered preventative treatment every shift.
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