Failure to Identify and Address Bed Wheel Hazards Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards by not identifying and addressing risks related to resident beds, specifically the bed wheels. A resident was injured when their bed moved during care, causing the resident to strike their head against a nearby stand and sustain two lacerations. Investigation revealed that the bed's wheel lock was defective, allowing the bed to move even when locked. Staff statements indicated that the malfunctioning bed had been an ongoing issue for months, and the problem had not been reported to maintenance or management prior to the incident. Review of the facility's preventive maintenance policy and logs showed that while there were procedures for bed safety audits, these did not include inspection or maintenance of bed wheels, their function, or brakes. The policy focused on other aspects of bed safety, such as mattress condition and side rail necessity, but omitted requirements for checking the operational status of bed wheels. The administrator confirmed that the preventive maintenance policy did not address bed wheel inspections.