Failure to Prevent Accident Hazard Related to Bed Controls for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with severe cognitive impairment, dementia, and significant physical limitations. The resident was dependent on two staff members for transfers and positioning, had poor safety awareness, and was unable to safely operate the bed controls. Despite staff being aware of the resident's unsafe use of the bed controller and concerns about potential injury, the facility did not identify or address the risk associated with the resident's inability to use the bed controls safely. On the day of the incident, the resident was found in distress, holding the bed controller, and reaching toward the bed, possibly attempting to self-transfer from her wheelchair. She was noted to have swelling and pain in her left lower leg, and a STAT X-ray revealed fractures of the tibia and fibula. The facility's investigation concluded that the likely cause of injury was the resident unknowingly lowering the bedframe onto her legs due to her confusion and inability to operate the bed controls appropriately. The care plan did not address the risk of injury related to the bed controls, despite the resident's known cognitive and physical limitations. Staff interviews confirmed that the resident had previously been observed using the bed controller unsafely, and some staff had even hidden the controller from her. The facility's policies required evaluation and implementation of safety interventions for residents at risk of falls or injury, but these were not updated to reflect the specific hazard posed by the bed controls. The manufacturer's manual for the bed also warned of increased risk for users with cognitive impairment, emphasizing the need for frequent monitoring, which was not adequately implemented in this case.