Failure to Maintain Bed Safety Mechanisms Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents. Specifically, the locking mechanism on the resident's bed was not operating properly, which resulted in the bed moving during care. This malfunction directly led to the resident falling from the bed, hitting her head, and sustaining a head injury, laceration above her right eye, and a skin tear on her forearm. The resident required emergency medical attention and received sutures for her injuries. The resident involved had a complex medical history, including cerebral infarction, dysphagia, hypertension, osteoarthritis, rheumatoid arthritis, chronic kidney disease, atrial fibrillation, repeated falls, and was prescribed anticoagulant medication. She was nonverbal, had moderate cognitive impairment, and required partial to moderate assistance with most activities of daily living. The care plan identified her as being at risk for falls and included interventions such as prompt assistance with ADLs, ensuring the call light was within reach, and using appropriate footwear. Despite these interventions, the malfunctioning bed lock was not addressed, which contributed to the accident. Observations and interviews confirmed that the bed's wheel locks were not functioning at the time of the incident and that other beds in the facility also lacked slip-resistant pads, allowing for movement even when locks were engaged. Staff interviews revealed that the bed's faulty lock was known and that the bed moved during care, directly causing the resident's fall. The facility's failure to maintain bed safety mechanisms and promptly address known hazards led to the incident and placed other residents at risk for similar accidents.