Failure to Lock Bed Brakes Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to ensure that the brakes on a resident's bed were locked during care, resulting in a fall with minor injury. The resident involved had Alzheimer's disease, adult failure to thrive, osteoarthritis, osteoporosis, and anxiety, and was assessed as having severely impaired cognition and being at high risk for falls. She required assistance with bed mobility and transfers, and her care plan included instructions to keep her bed in an appropriate position for safety. During incontinence care, a CNA unlocked the bed to move a mechanical lift and forgot to relock it, causing the bed to move and the resident to fall out of bed onto the CNA. Review of documentation and interviews revealed that the CNA had received prior training on locking bed brakes but did not attend a recent mandatory clinical meeting that reinforced this requirement. The facility's policy and the manufacturer's instructions for the bed emphasized the importance of locking the bed for resident safety. The incident report and staff interviews confirmed that the bed was not locked at the time of the fall, directly leading to the accident.