Failure to Address Defective Mattress Causing Ongoing Pain and Discomfort
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, comfortable, and homelike environment for a resident with chronic severe pain by not addressing a defective mattress that contributed to the resident’s discomfort and difficulty sleeping. The resident, cognitively intact and admitted with diagnoses including right hip pain, left shoulder pain, osteoporosis with pathological fracture, insomnia, and unspecified pain, had a care plan that called for acknowledging pain, assessing its effects on sleep and activity, monitoring non-verbal pain signs, and positioning for comfort. The resident’s MDS documented almost constant severe pain (rated 8/10), frequent interference with day-to-day activities, and occasional sleep disturbance due to pain, with both scheduled and PRN pain medications in use. Progress notes showed the resident yelling for assistance to get into bed. During interviews, the resident repeatedly reported that the bed had a dip or “hole” that caused significant lower back pain, made it difficult to get out of bed, and prevented decent sleep, stating that staff were aware because the resident had told several staff members and yelled out at night due to the pain. A CNA confirmed that the resident complained of hip and back pain and specifically of a dip in the mattress that the resident fell into, and noted the mattress could not be flipped and that the resident had slept in a recliner for a few nights to see if that helped. The DON acknowledged that the resident slid down in bed, yelled out at night about slipping into a hole in the bed, had not personally inspected the mattress, and believed any bed issues should be in the maintenance book, while also stating the resident should have a comfortable mattress. The Administrator reported being unaware of the bed-related pain or nighttime yelling and stated staff could have changed the mattress and should notify nursing or housekeeping if a resident had a bed concern. Despite these reports and the resident’s documented chronic severe pain, the mattress issue was not addressed, resulting in the resident’s ongoing discomfort and inability to rest comfortably.
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