Failure to Lock Bed Brakes After ADL Care
Penalty
Summary
A deficiency was identified when staff failed to ensure that a resident's bed brake lock was engaged, resulting in the bed being left unlocked. The resident in question had been admitted and readmitted with diagnoses including failure to thrive, and was assessed as severely cognitively impaired, requiring staff assistance for activities of daily living such as showering, toileting, dressing, and personal hygiene. The resident's care plan indicated a need for assistance with ADLs due to poor balance and gait instability, and the resident was determined to be at medium risk for falls. During an observation, it was noted that the brake at the foot of the resident's bed was not locked, and this was confirmed and corrected by the maintenance resource at the time. Interviews and policy reviews revealed that facility policy requires all staff to ensure that resident beds are locked and in a safe position after providing ADL care, and that beds should be returned to the lowest position with wheels locked unless otherwise indicated in the care plan. The Director of Nursing confirmed that bed brakes should be locked to prevent movement. The failure to follow these procedures resulted in the resident being placed at risk for injury due to the unsecured bed.