Failure to Inspect and Maintain Safe Bed Equipment
Penalty
Summary
A deficiency was identified when the facility failed to regularly inspect a resident's bed frame and mattress as part of its maintenance program, specifically to identify areas of possible entrapment. The resident involved had a diagnosis of dementia with severe cognitive impairment, as indicated by low BIMS scores, and was dependent on staff for bed mobility. Observations revealed a persistent gap of approximately six inches between the top of the mattress and the head of the bed. Staff interviews confirmed that the mattress had been shorter than the bed frame for an extended period, and maintenance staff had not checked the bed because it was supplied by hospice and not considered a facility bed. The resident's care plan noted that hospice would provide the bed and mattress, but there was no evidence that the facility ensured the equipment was safe or properly fitted. The facility's policy required reasonable accommodations to individualize the resident's environment, including the bedroom, but this was not followed in this case. The lack of inspection and failure to address the mismatch between the mattress and bed frame placed the resident at risk for injury.