Failure to Implement Preventative Maintenance Program for Beds and Side Rails
Penalty
Summary
The facility failed to develop and implement a preventative, regular maintenance program for resident beds and side rails, which resulted in the lack of routine safety inspections and maintenance for all beds and side rails in use. Observations revealed that several residents had beds with bilateral, chrome-colored metallic half side rails that were loose and moved several inches side-to-side when touched, despite being attached to the bed frame. Interviews with residents indicated that they were not consulted about the use of side rails or offered alternative devices prior to installation, and some residents had signed consent forms without being asked about their preferences. Review of facility documentation and interviews with staff, including the DON, facilities manager, and environmental services director, confirmed that there was no ongoing, routine maintenance program for beds or side rails. Maintenance was only performed in response to specific work orders, such as when a side rail was found to be loose or when a resident was discharged and the bed was prepared for a new occupant. The environmental services staff performed monthly bed washes and terminal cleaning but did not check for preventative maintenance or potential entrapment hazards, and these activities were not documented or tracked for maintenance purposes. The facility was unable to provide a policy on bed maintenance, and the provided work order records lacked evidence of any ongoing preventative screening or maintenance review to ensure bed safety. Staff interviews further revealed uncertainty about responsibilities for bed and side rail safety checks, and there was no documentation of routine inspections or adherence to manufacturer recommendations for annual maintenance. These deficiencies had the potential to affect all residents using beds and side rails at the facility.