HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure that the patient's care plan concerning the specialty bed for the treatment of pressure wounds is plugged in and functioning at all times to deliver its intended therapeutic function.

Findings include:

Facility policy titled, "Skin Care to Reduce the Risk of Pressure Injury" (Reviewed: 02/14/2023) stated, " ... I. Purpose: A. Provide guidance for appropriate skin assessment and use of nursing interventions to improve patient outcomes and reduce the risk of pressure injury in the adult and pediatric patient population. II. Scope: A. Members of the patient care team, including but not limited to RNs ... who are responsible to maintain a patient's skin integrity and reduce the risk of pressure injury. III. Policy: A. The care of skin breakdown, including reducing the risk of pressure injury, skin tears ... is an interdisciplinary team approach ... D. Interventions are to be put into place to reduce the risk of Hospital Acquired Pressure Injuries ... IV. Policy Implementation: ... 7. Nursing Interventions: Implement ... Skin Care Bundle (See Appendix A) including measures to reduce risks of pressure injuries ... Appendix A ... IV. Bed/Chair Pressure Redistribution: ... Therapeutic: ... Dolphin Immersion mattress."

Facility policy titled, "Incoming Inspection of all New Leased or Rented Patient Care Equipment" (Reviewed: 12/12/2022) stated, "I. The purpose of this policy is to establish a system which provides medical equipment safety and an understanding for the approval and preventative maintenance inspection of newly acquired biomedical/clinical equipment ... III Procedure: ... B. Equipment maintained by the manufacturer/vendor under a service agreement will also be included in the equipment management program where services will be monitored and recorded.

Facility policy titled, "Red Tag for Equipment Repair" (Reviewed: 01/05/2023) stated, "I. Purpose: A. To ensure accurate and timely repairs of all medical devices and to promote effective communications as it relates to the repair of medical devices ... II. Policy: A. All manufacturing medical device shall immediately be reported to the Clinical Engineering Department. B. Malfunctioning equipment shall be removed from service with a red tag attached to the equipment ..."

On 04/02/25 at 11:44 AM, medical record review was conducted with Staff (S)3 (Senior Informatics Analyst) and revealed that Patient (P)1 had been placed on a Dolphin Immersion mattress [a specialty bed that simulates the effects of a body immersed in a fluid] for the treatment of a stage IV (four) pressure injury of the sacrum.

On 11/04/2024 at 11:02 PM, a Nursing Note documented by S28 (Registered Nurse [RN]) revealed, "1930 [7:30 PM] Pt [patient] with visitor ([Complainant] and [Spouse]) at bedside. [Complainant] upset about pt [patient] bed being unplugged and states [he/she] had someone ... come check on [the patient] earlier in the day and they filed a maintenance request about the bed being unplugged for [him/her] ... This RN plugged the bed back [in] and left the room."

The duration for which the patient's specialty bed failed to provide its intended therapeutic function due to being unplugged could not be determined. There was no documented evidence that the specialty bed was functioning after it was plugged in. S1 (Director of Relations and Affairs) confirmed that the Dolphin Immersion mattress is required to be plugged in to provide the prescribed therapy. Upon request, S1 was unable to provide a maintenance request.

On 04/02/25 at 11:44 AM, upon interview, S1 confirmed the above findings and stated, "an unplugged bed would not have generated a maintenance request. For the bed to have been looked at, a red tag would have had to been placed on the bed with the reasoning and then removed from the patient's room. A phone call would then be placed to our engineering department to make them aware of it. I do not see a red tag request was placed for this patient's bed."