Failure to Address Broken Bed Footboard and Resident Safety Hazard
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for mobility and had significant cognitive and physical impairments, was left in a bed with a broken footboard that had detached and remained on the floor for several hours. During this time, the resident's feet were observed dangling at the foot of the bed, and the resident was sliding down due to the absence of the footboard. Multiple staff members, including a CNA, LVN, and RNA, observed the broken footboard and the resident's compromised position but did not immediately report the issue or request maintenance. The CNA, who was assigned to the resident, acknowledged seeing the broken footboard at the start of the shift but failed to notify the charge nurse or maintenance. The maintenance manager confirmed that no repair request had been submitted until much later, and the RN supervisor, who was responsible for conducting room rounds, had not identified the issue during their checks. The resident's medical history included unspecified abnormalities of gait and mobility, encephalopathy, and myocardial infarction, and the resident required maximal assistance for bed mobility and transfers. Facility policy required staff to report environmental hazards and ensure resident safety, but these procedures were not followed, resulting in the resident being left in a hazardous situation for an extended period. Interviews with facility leadership, including the DON and DSD, confirmed that staff were trained to report such hazards immediately, and the failure to do so was recognized as a significant lapse in standard care.