Failure to Ensure Functioning Air Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a high‑risk resident received necessary pressure injury prevention services as required by physician orders, the care plan, and facility policy. The facility’s pressure injury policy states a commitment to preventing avoidable pressure injuries and providing appropriate treatment and services. The resident had a physician order dated 3/14/24 directing that the air mattress function be checked to ensure the green light is on and, if the light is red, to turn the air mattress on every shift. The resident’s care plan and Kardex also included an intervention to check the function of the air mattress every shift. The resident had multiple diagnoses including diabetes mellitus, dementia, congestive heart failure, major depressive disorder, atrial fibrillation, and hypertension, and was identified as high risk for pressure injuries with a Braden score of 10. The resident was dependent for toileting hygiene and rolling, always incontinent of bowel and bladder, and had a history of pressure injuries to the buttocks and right medial heel that had resolved on 2/25/26. The Pressure Ulcer/Injury CAA documented contributing factors such as ADL/functional/mobility impairment and incontinence, and indicated that licensed nurses were to assess skin weekly and implement proper interventions, with caregivers assisting with repositioning at least every two hours. Despite these identified risks and documented interventions, surveyor observations on two consecutive days showed that the resident’s Proactive Protek Aire 8000 air mattress pump was not functioning on multiple occasions, with no lights lit on the pump unit attached to the footboard of the bed. The resident was repeatedly observed lying in bed on his back with the head of the bed elevated while the air mattress pump remained off. When questioned, an LPN acknowledged that air mattresses for residents who have them should be on and stated they had not noticed the pump was off, explaining they usually complete the TAR at noon and suggesting a generator check may have shut off the air mattress. The RN/Unit Manager stated that nurses should check orders, listen for alarms, and that staff should feel the mattress during cares, but no explanation was provided by leadership for why the resident’s air mattress was not functioning during the observed periods.
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