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Based on observation, interview, and record review, the facility failed to ensure patient's right to safe care when the facility did not implement and enforce a policy and procedure for the use and cleaning of the Arjo air mattress. This failure places all patients with orders for an Arjo mattress at risk of contact dermatitis from caustic cleaning chemicals and bacterial infections from improperly cleaned bedding.

Findings:

Observations on the afternoon of 6/6/23, on the facility's inpatient Intensive Care unit, revealed Patient # 15 had her lower legs, heels, and upper back in direct contact with the Arjo mattress.
On the morning of 06/07/2023, patients # 16 and 17 were observed lying on an Arjo mattress, their heels were in direct contact with the Arjo mattress.

During an interview, on 06/06/23 at 2:00 pm in the ICU, when asked how the Arjo mattress was cleaned, Staff #, 13, RN stated, "I use the wipes (Sage Comfort Bath Cleansing Washcloths) that I use on the patients." When shown Patient #15's soiled mattress, which had become exposed due to the patient being up in a bedside chair, Staff #13 quickly wiped the mattress down with the Sage wipe. The soiled area had been where the patient's upper back had been directly in contact with the Arjo mattress the previous evening.

During an interview, on 06/06/23 at 3:00 pm in the Administrative conference room, when asked for the policy and procedure for the manufacturer's user's manual, detailing the use and cleaning of the Arjo mattresses, Staff #1, Quality Director stated, "We don't have one. We only have what corporate gave us. We were told, don't place bedding between the patient and the mattress."

Review of the facility-provided Arjo Sin IQ Microclimate Manager Clinical Guidelines reflected, "Limit layers on Skin IQ, use single flat sheet and DriFlo pads."

During an interview, on 06/07/23 at 10:00 am in the ICU, when asked how the Arjo mattress was cleaned, Staff #, 12, RN stated, "I clean the mattresses every day. I use the purple wipes (Sani-Cloth Prime). I just wipe it clean."
Staff #12 did not indicate if a drying time was required or if the product was safe to expose to a patient.

Review of the facility provided material safety data for Product Name: Sani-Cloth® Prime Germicidal Disposable Wipe (Canister) reflected, "Finished Product Number: N/ A Formula Item Number: 4OP25301 Date of Preparation: July 17, 2018
Recommended use of the chemical and restrictions on use:
Recommended use: Use as a disinfectant on hard, non-porous surfaces. Read and understand the entire label before using. Use only according to label directions.
Precautionary Statements: Hazards to humans and Domestic Animals.
Causes substantial but temporary eye damage. Wash hands thoroughly with soap and water after handling."