Failure to Timely Repair Bedrail Results in Resident Fall and Injury
Penalty
Summary
A resident with a history of left above-the-knee amputation, repeated falls, and other medical conditions required bilateral bedrails for safe transfers, turning, and positioning, as documented in the physician's orders and care plan. The resident's left bedrail became detached from the bed, and although staff were aware of the issue, the bedrail was not repaired or replaced in a timely manner. The maintenance work order for the repair was not submitted until after the resident experienced a fall. On the night of the incident, the resident attempted to sit up on the edge of the bed and reached for the missing left bedrail, lost balance, and fell forward onto the floor, resulting in a right femur fracture and head injury. Staff interviews confirmed that the resident frequently self-transferred without assistance and that the left bedrail had been broken prior to the fall. The CNA and nurse on duty were aware of the broken bedrail but did not ensure that the maintenance request was promptly entered or that the resident's environment was made safe in the interim. The facility's fall reduction policy required identification of residents at risk for falls and implementation of appropriate interventions, including assistive devices. Despite this, the necessary assistive equipment was not provided as required, and the lack of timely repair or replacement of the bedrail directly contributed to the resident's fall and subsequent injury.