Failure to Repair Broken Headboard Creates Accident Hazard
Penalty
Summary
A deficiency was identified when the facility failed to repair a broken headboard for a resident, which created an accident hazard. The resident, who had a history of stroke, hypertrophic cardiomyopathy, and delusional disorders, was cognitively intact according to her most recent MDS assessment. During an observation and interview, the resident was found in bed with bruising on her right arm. She stated that the headboard had been broken and was later fixed by maintenance. However, prior to the repair, a registered nurse discovered the headboard on the floor and a metal bracket from the headboard in the resident's bed while making rounds. An investigation was initiated due to the bruising, which was considered an injury of unknown origin. A certified nursing assistant reported that the resident was agitated during the night, refused care, and was observed banging her arm on the bedside table. The CNA moved the table to prevent further injury but did not report the broken headboard, despite having seen it on the floor a week earlier. The administrator confirmed that accident hazards should be reported to prevent resident harm and acknowledged that the resident had a piece of the metal headboard in her bed. The failure to promptly report and repair the broken headboard resulted in a hazardous environment for the resident.