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F0909
D

Failure to Maintain and Document Bedframe Safety Inspections

Alturas, California Survey Completed on 06-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain bedframes in accordance with its own policies, manufacturer recommendations, and its Medical Equipment Management Plan. Specifically, the facility's policies required that electronically operated patient beds be included in the Equipment Management Program, with scheduled and documented preventative maintenance. The Medical Equipment Management Plan also required maintenance based on manufacturer recommendations, which specified that bedframes should be thoroughly and visually inspected monthly. However, interviews and record reviews revealed that bedframes were only being inspected quarterly, and there was no documentation to show that regular safety inspections of bedframes had been performed. A resident with a history of CVA and atrial fibrillation reported that the footboard of their bed had broken off, but could not specify when the incident occurred. The Maintenance Lead confirmed that there was no work order documenting the breakage or repair of the footboard, and that a weekly safety checklist for headboards and footboards had been created only after the incident, but had not yet been implemented. The lack of regular inspections and documentation had the potential to subject all residents to injury from inadequately maintained equipment.

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