Failure to Regularly Inspect and Maintain Bed Rails
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to implement a scheduled maintenance program for bed rails as required by its own policy, which states that individual bed rail assessments and evaluations should be performed regularly. A resident with a history of heart failure and atrial fibrillation was admitted and later experienced an incident where they were found on the floor with a hematoma to the left side of the head. Nursing documentation revealed that the right-side bed rail was broken and would not lock in place at the time of the incident. The Director of Maintenance confirmed that prior to the incident, bed rails were only checked when preparing a room for a new admission, and not on a regular schedule.