Failure to Provide Adequate Bed and Adaptive Devices for Resident with Paraplegia
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with paraplegia, anxiety, depression, and multiple Stage 4 pressure ulcers by not providing a bed wide enough for safe repositioning and by not supplying requested adaptive devices such as side rails and a trapeze bar. Observations showed the resident lying on an air mattress with only about four inches of space from their hips to the edge of the mattress, without side rails or a trapeze bar present. The resident reported being accustomed to using these devices for bed mobility and expressed feeling claustrophobic and restrained due to the bed's size and lack of support, resulting in complete dependence on staff for repositioning and a fear of falling during transfers. The facility's policy required evaluation and ongoing review of residents' needs for adaptive devices and environmental modifications. Despite the resident's requests for side rails upon admission and a trapeze bar shortly thereafter, the facility did not provide these accommodations, citing a policy against full side rails and a delay in providing the trapeze bar. The DON stated they relied on nursing and therapy staff to communicate such needs and were unaware that the resident's bed did not adequately accommodate them.