Failure to Maintain Resident Bed in Safe Working Condition Resulting in Fall and Injury
Penalty
Summary
The facility failed to ensure that essential resident equipment was in good working condition, specifically for a resident who had a recent below-the-knee amputation and required assistance with transfers. The resident's bed had a malfunctioning locking mechanism, which allowed the bed to roll. Despite the resident's complaints about the bed not locking, the issue was not addressed in a timely manner. The resident attempted to self-transfer from the bed to a wheelchair, and the bed rolled away, causing the resident to fall to the floor. This fall resulted in the reopening of the surgical incision site on the amputated limb, leading to significant bleeding and the need for urgent hospital treatment and surgical revision. Interviews and record reviews confirmed that the resident had reported the bed's malfunction to staff, and maintenance staff were aware of the issue. However, there was confusion among staff regarding when the problem was reported and when action was taken. The resident stated that after the fall, he activated his call light but did not receive immediate assistance, leading him to crawl into the hallway to seek help. Staff eventually responded and provided care, but the delay and the equipment failure directly contributed to the resident's injury.