Failure to Lock Bed Brakes and Provide Supervision During Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of intracranial hemorrhage, cervical osteomyelitis, cervical discitis, and cervical spondylolisthesis was left unattended in bed prior to transfer using a mechanical lift. The resident's care plan identified poor safety awareness, a tendency to raise the bed to a high position, generalized muscle weakness, and a high risk for falls and injury, requiring fall precautions, frequent visual checks, and safety measures during transfers. On observation, the resident was found lying flat in bed with the bed elevated, side rails down, and the brakes at the foot of the bed not locked. Two wheelchairs were blocking the entrance to the room, and the resident's Foley catheter bag was on the bed next to her. Staff interviews confirmed that the bed brakes were not locked prior to transfer and that the bed should have been in the lowest position to prevent falls. The care plan and facility policy required maintaining the bed in the lowest position and locking brakes for high-risk residents. Staff acknowledged that the resident should not have been left unattended with the bed elevated and brakes unlocked, as this could result in a fall. The facility's policy also emphasized keeping the environment free of unnecessary obstacles and increasing supervision for residents at high risk for falls.