Resident Injured Due to Unlocked Bed During Incontinent Care
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including chronic obstructive pulmonary disease, peripheral vascular disease, and an above-the-knee amputation, was injured during incontinent care. The resident, who had moderate cognitive impairment and required substantial assistance for mobility and hygiene, was being assisted by an LVN. During the care, the LVN raised the bed and attempted to roll the resident, but the bed was not properly locked. As a result, the bed rolled into the wall, causing the resident to strike the wall with her foot, head, and left hand. Following the incident, the resident sustained multiple injuries, including fractures to the second and third metatarsals of the left foot and a distal ulna fracture in the left wrist, as confirmed by X-rays and orthopedic evaluation. Additional injuries included bruising and abrasions to both hands, a skin tear to the left hand, and redness and bruising to the left side of the forehead. The resident and her family reported that the injuries were a direct result of the bed rolling during care, and the LVN acknowledged that he believed the bed was locked but it still moved when he leaned against it. Interviews with facility staff revealed that the bed had six brakes, with only one found to be loose, and no mechanical reason was identified for the bed's movement if the brakes were properly engaged. The facility's policies on bed safety and resident safety did not specifically address the requirement to lock beds during incontinent care. The incident led to the resident requiring two-person assistance for future care, but the deficiency was due to the failure to ensure the bed was locked and the environment was free from accident hazards during care.