Failure to Identify and Address Bed Safety Hazards Resulting in Resident Injury and Entrapment Risk
Penalty
Summary
The facility failed to identify and address hazards in the resident environment, specifically related to bed safety, which resulted in avoidable accidents and injuries. One resident sustained a skin tear on the right arm after falling and striking an exposed, uncovered section of the bed frame where the mattress did not fully cover the frame. The exposed area included a mechanical hinge, screw, and sharp metal edges due to missing plastic caps. The resident self-reported the incident, and clinical documentation confirmed the injury and subsequent pain during wound care. Observations by surveyors and interviews with staff confirmed that the mattress was not the correct size for the bed frame, leaving hazardous areas exposed. Another resident was observed lying in bed with several inches of the bed frame exposed on both sides of the mattress, creating multiple areas for possible entrapment of body parts. The bed rail at the resident's head was measured to be 10 inches from the mattress, exceeding recommended safety limits and presenting a risk of entrapment. The maintenance supervisor acknowledged that the bed frame was wider than the mattress and that staff had independently adjusted bed equipment without proper oversight or knowledge of safety requirements. The administrator confirmed that staff had made changes to bed mattresses without notifying administrative staff, and the risk for accidents or injuries associated with exposed bed frames was not identified by staff. The facility's Bed Safety policy required regular inspection of beds and related equipment, adherence to FDA guidelines for bed system dimensions, and reporting of injuries related to bed equipment. However, maintenance staff were unfamiliar with the proper use of measurement tools and the required safety dimensions. Documentation and interviews revealed that inspection protocols were not effectively implemented, and hazards were not reported or addressed, resulting in an immediate jeopardy situation for all residents.