Failure to Provide Appropriately Sized Bed for Resident with Mobility Limitations
Penalty
Summary
The facility failed to provide a comfortable and appropriately sized bed for a resident with multiple complex medical diagnoses, including partial paralysis and a pain syndrome. The resident was assessed as having functional limitations in both arms and legs and was dependent on staff for mobility and repositioning. Observations showed the resident's feet were propped on pillows over the footboard, and their head was higher than the mattress, indicating discomfort. The resident reported persistent discomfort, describing the bed as too small and the mattress as bowed, with both ends raised compared to the middle. The resident stated that a foam spacer was used to fill the gap between the mattress and the extended bed frame, but the spacer often shifted, causing further discomfort and preventing the bed from lying flat. The resident reported these issues to staff multiple times but was told there was nothing more that could be done. Staff interviews confirmed awareness of the bed's limitations, with maintenance having extended the bed frame but not providing a longer mattress. Staff acknowledged the use of a foam spacer to compensate for the mattress's short length, but were unaware that the spacer could slide and elevate the foot of the bed, making it difficult for the resident to sit up or reposition. The Director of Nursing stated that although the mattress had been changed several times, they were not aware that the current configuration prevented the bed from being fully lowered. The facility had longer beds available, but the resident was not provided with one, resulting in ongoing discomfort and inadequate accommodation of the resident's needs.