Failure to Maintain Resident Bed in Safe Operating Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was maintained in a safe and functional condition at all times. The resident, who had diagnoses including dementia, anxiety, intellectual disabilities, and gastrostomy status, was observed on multiple occasions with the head of bed (HOB) in a flat position due to a malfunctioning bed. Certified Nursing Assistant (CNA) #23 reported that the bed had been broken since the previous day, and the Maintenance Director (MTD) was not informed until a day later. The resident remained in the non-functioning bed for at least two days, during which time the HOB could not be elevated for care or feeding. Interviews with staff revealed a lack of timely communication regarding the bed's malfunction. CNA #23 was unsure when the issue was reported to maintenance, and the MTD stated he was not informed until the day after the problem was first noticed. The Director of Nursing (DON) also confirmed she had not been notified of the issue. Staff acknowledged the importance of a functioning bed, particularly for residents who require the HOB to be elevated during feeding to prevent choking or aspiration, and for general safety and care needs.