Failure to Maintain Safe Resident Equipment Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident's bedroom furniture in a safe condition, resulting in an injury. The resident, who had a history of respiratory failure, COPD, and type II diabetes, sustained a laceration to the top of her right foot after her foot came into contact with a torn and rough footboard while she was attempting to sit up in bed. The incident happened in the early morning hours, and the wound required hospital treatment, including the placement of seven sutures. Documentation and interviews confirmed that the footboard was in a state of disrepair at the time of the incident. Further review and staff interviews revealed that the rough patch on the footboard had not been addressed prior to the injury. There was no evidence provided to show that the facility had an effective system in place for the ongoing maintenance and timely repair of resident equipment to prevent such injuries. The resident's medical condition, including significant leg swelling and fragile skin, increased her vulnerability to injury, but the unsafe condition of the footboard was the direct cause of harm.