Failure to Secure Bed Side Rail Results in Resident Fall and Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a side rail was securely attached to a resident's bed, resulting in a fall that required hospitalization. The resident involved had significant medical conditions, including congestive heart failure, chronic kidney disease, respiratory failure, morbid obesity, and was dependent on staff for mobility and activities of daily living. The care plan specified the use of 1/4 side rails on both sides of the bed to assist with mobility and positioning, and the facility's policy required regular inspection and maintenance of bed systems, including side rails. On the day of the incident, the resident was being assisted by a CNA for personal care. As the resident turned and held onto the left side rail, the rail detached from the bed frame, causing the resident to fall to the floor and sustain a bruise and pain to the right leg. Interviews and documentation revealed that the pins securing the side rail to the bed frame were missing at the time of the fall, which allowed the side rail to become unattached. The maintenance staff confirmed that the absence of these pins was a safety risk and directly contributed to the incident. Routine monthly inspections of beds and side rails were documented, and the most recent inspection prior to the incident did not identify any issues. However, the staff responsible for weekly checks of side rails did not specifically assess whether the securing pins were in place, only checking for general stability. The failure to ensure the side rail was properly secured with the required pins led to the resident's fall and subsequent hospitalization for evaluation and treatment of injuries.