Improper Installation of Bed Rails Using Zip Ties
Penalty
Summary
The facility failed to ensure that bed rails were installed in accordance with the manufacturer's recommendations and specifications for one resident. The resident, who had a history of muscle weakness, unsteadiness, reduced mobility, cerebral infarction, and hemiplegia, required substantial to maximal assistance with mobility and used bed rails to reposition herself. Upon admission to a new room, the resident's previous bed rails were attached to the new bed frame using zip ties instead of being bolted, as they were not compatible with the new bed. Staff and the maintenance supervisor confirmed that the rails were not designed for the current bed and that zip ties were used as a temporary measure until the correct rails arrived. The bed rails were observed to be loose and unstable, and the facility did not have the manufacturer's instructions for the bed. The resident and staff reported that the bed rails were necessary for the resident's mobility and repositioning in bed. Despite this, the rails remained improperly attached for several days, as confirmed by multiple observations and interviews. The facility's own policy required that bed rails be installed according to the manufacturer's instructions to ensure safety, but this was not followed, resulting in the deficiency.