Failure to Inspect and Maintain Bed Safety Results in Resident Injury
Penalty
Summary
The facility failed to conduct routine inspections and maintenance of resident beds, specifically neglecting to address exposed metal brackets intended for footboards on nine beds. One cognitively impaired resident with a history of falls was found after a crash was heard, lying on her side with her left buttock impaled by a metal bracket at the end of her bed. The bracket, which was designed to hold a footboard, was exposed and had entered and pressed against the resident's buttock. Multiple staff interviews confirmed that these metal brackets, some with pointed tops extending upwards, had been present on beds in use for an extended period without footboards attached. The Maintenance Director acknowledged that the beds with exposed brackets had been in use since before his tenure began, and the Nursing Home Administrator was unaware of how long the beds had been in this condition. Review of facility work orders over several months showed that none of the nine beds with exposed brackets had been reported or addressed for maintenance. Staff interviews further confirmed the presence of the hazardous brackets and the lack of footboards, directly leading to the resident's injury.