Failure to Secure and Inspect Bed Positioning Devices
Penalty
Summary
The facility failed to ensure that bed rails, used as positioning devices, were properly secured and regularly checked for safety for one resident. Multiple observations over several days revealed that the resident's left side positioning device was loose and able to wiggle. The resident, who had diagnoses including Parkinson's disease, hemiplegia, and dementia, reported using the devices to assist with turning in bed and confirmed that the left device was loose. Staff interviews confirmed that the device was not secure and should have been, and that the process for addressing such issues involved submitting a work order and notifying management. Review of facility policies and documentation showed that while bed positioning devices were expected to be checked during weekly room rounds, the room rounds form did not specifically list these devices for inspection. Instead, checks were documented under general categories such as "Is the room in good repair" and "Furniture in good repair." The Director of Facilities stated that bed positioning devices were not included in routine maintenance checks, and the Administrator clarified that managers were expected to check these devices as part of the bed during room rounds. However, the loose device was only identified when a work order was submitted, indicating a lack of specific, documented inspection for bed positioning devices.