Failure to Lock Bed Casters for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when staff failed to lock the casters on the bed of a resident with a known history of falls and high fall risk. The resident, who had diagnoses including type 2 diabetes mellitus, gait and mobility abnormalities, and muscle weakness, was assessed as requiring partial to moderate assistance with transfers and had experienced multiple falls since admission. During an observation, the resident was seen attempting to get out of bed by holding onto the side rail and bedside table, while the bed moved due to the casters being left unlocked. The resident expressed confusion about the bed's movement. The Assistant Director of Nursing confirmed that the bed casters were left unlocked, which allowed the bed to move and could contribute to another fall. Review of the manufacturer's manual indicated that unlocked casters could result in involuntary bed movement and potential injury. Facility policy required beds to be in the lowest position with brakes locked, but this was not followed in this instance.