Failure to Complete Air Mattress Safety Assessments
Penalty
Summary
The facility failed to complete required air mattress safety assessments for two residents who were using air mattresses. For one resident, a significant change MDS dated February 13, 2026, showed that the resident was cognitively intact and required staff assistance for daily care. The resident’s care plan, dated December 12, 2025, identified potential or actual impairment to skin integrity and included an intervention for use of an alternating air mattress to maintain intact skin. Observation on March 23, 2026, confirmed that this resident was using an air mattress on the bed. Review of the clinical record revealed no documented evidence that an air mattress safety assessment had been completed, and the Nursing Home Administrator confirmed that such an assessment should have been performed but was not. For the second resident, a quarterly MDS dated January 27, 2026, indicated that the resident was cognitively impaired, dependent on staff for daily care, and receiving hospice services. A care plan dated February 3, 2026, documented that the resident had an alternating air mattress provided by hospice. Observation on March 23, 2026, showed that this resident was in bed with an air mattress in use. Review of the clinical record revealed no documented evidence of an air mattress safety assessment for this resident. In an interview, the Nursing Home Administrator confirmed there was no documented air mattress safety assessment for this resident, despite the use of the equipment. These findings were cited under 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
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