Failure to Maintain Safe and Functional Bed Equipment
Penalty
Summary
The facility failed to ensure that essential patient care equipment, specifically resident beds, was maintained in safe operating condition for three residents. One resident's bed lacked brakes on the foot of the bed, and the bed could be easily moved with minimal force. Another resident's bed had one brake on the foot that would not lock, and the other brake was not locked when checked, resulting in the bed being easily movable. A third resident's bed had a malfunctioning remote control, with only one button working incorrectly, and the resident was unable to control the bed's position as intended. In each case, the residents reported the issues, and observations confirmed the equipment was not functioning as required. The affected residents had significant mobility limitations and medical conditions, including muscle weakness, morbid obesity, anxiety disorder, multiple sclerosis, and recent fractures. Care plans indicated extensive assistance was needed for bed mobility and transfers, with one resident requiring a mechanical lift. Despite these needs, the maintenance supervisor was unaware of the equipment issues until the time of the survey and stated that he relied on staff to report problems. The deficiencies were identified through resident interviews, direct observation, and review of care plans and assessments.