Failure to Securely Fasten Bed Rail
Penalty
Summary
The facility failed to ensure that a bed rail was securely fastened to the bed for one resident. The resident was observed on multiple occasions with a quarter length bed rail on the left side of the upper bed that was loose, with four to five inches of movement up and down and five to six inches of movement back and forth. The bracket attaching the bed rail to the bed frame was also observed to be loose, wiggling about one inch around the bolt. The resident reported to staff several times that the bed rail was loose, but it had not been fixed. Staff interviews confirmed that the process for reporting broken equipment, such as bed rails, involved submitting a work order through the TELS electronic system and verbally notifying maintenance. A CNA had submitted a TELS work order for the loose bed rail, but it remained unrepaired for several days. The Chief Nursing Officer acknowledged that the bed rail was looser than it should have been and that safety-related issues like this should be addressed immediately. The facility's policy required correct installation, use, and maintenance of bed rails, but this was not followed in this instance.