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F0689
G

Failure to Maintain Safe Bed Rail Results in Resident Injury

Sandwich, Illinois Survey Completed on 09-18-2025

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

A deficiency occurred when the facility failed to maintain a bed rail in a safe condition, resulting in a resident sustaining a significant injury. The resident, who had a complex medical history including severe cognitive impairment, reduced mobility, osteoporosis, repeated falls, and fragile skin, required substantial to maximal assistance for most activities of daily living and was dependent on staff for all transfers. During an attempt to transfer the resident from bed, a CNA noticed the resident was fearful and holding tightly to the side rail. As the transfer was being performed, the resident suddenly complained of leg pain, and a significant laceration with heavy bleeding was discovered on her right leg. The injury required hospital treatment and sutures. Investigation revealed that the side rail involved in the incident was missing its end caps, leaving rough, exposed metal edges. The CNA reported that the resident was not combative but was fearful and resistant to getting up, and that the injury occurred within minutes of starting the transfer. Maintenance staff later confirmed that multiple side rails throughout the facility were missing end caps, with a documented list showing over 20 side rails in need of repair or replacement of end caps. The maintenance director acknowledged that the end caps were installed and padding was added only after the incident occurred. Staff interviews and record reviews indicated that the resident had a history of multiple skin tears and wounds in recent months, and that the facility's policy required equipment to be monitored for good working condition and repairs as needed. The DON stated that staff are expected to report any equipment that might pose a safety issue and to remove it from service until repaired. The physician described the resident as extremely fragile, with a propensity for severe skin injuries, and expected that equipment used with such residents should be free of rough edges. The facility's investigation confirmed that the injury was caused by the exposed metal on the bed rail.

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