Failure to Maintain Bed Rails in Safe and Operable Condition
Penalty
Summary
The facility failed to ensure that bed rails for one resident were maintained in a safe and operable manner, resulting in the rails being loose and not securely fitted. Observations revealed that the resident was lying in bed with bilateral bed rails that could easily bend outward due to an unsecured, loose fit. The Director of Nursing confirmed the rails were very loose and not providing a secure, tight fit. The Maintenance Director and Administrator were unaware of the issue, and the last documented maintenance check did not identify any problems. The resident's electronic health record indicated severe cognitive impairment and diagnoses including anxiety disorder, vascular dementia with behavioral disturbances, and unspecified glaucoma, but no impairment in upper or lower extremities. The facility's Preventative Maintenance Program assigned responsibility for bed rail checks to the Maintenance Director, with monthly inspections reported. However, the loose rails were not identified or addressed until observed during the survey. The DON stated that CNAs were responsible for reporting such issues, but the problem persisted until the survey. The Maintenance Director confirmed that the knobs on the rails were loose and required tightening due to a loose screw.