Failure to Secure Bed Brakes for Dependent Resident
Penalty
Summary
Facility staff failed to ensure that the brakes were set on the hospital bed for one of four sampled residents during a random observation. The resident involved was admitted with multiple significant diagnoses, including chronic respiratory failure requiring a ventilator, chronic encephalopathy, and dementia. The resident was documented as being dependent on staff for activities of daily living and was rarely or never able to make decisions or provide meaningful information. During an observation, the resident was found lying in bed with the bed brakes unlocked and no staff present in the room. A registered nurse, upon noticing the unlocked brakes, acknowledged that this was dangerous and could cause a fall or injury. Review of the hospital bed's operations manual confirmed that brakes should always be applied when a resident is on the bed, and staff should ensure the brakes are locked by pushing on the bed after application.