Failure to Maintain Safe Bedframe Results in Resident Injury
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, resulting in a resident sustaining a significant injury. During a transfer from wheelchair to bed, a resident's leg was caught on a jagged, uncapped metal edge of the bedframe, causing an 18 cm by 5 cm avulsion skin tear that required six sutures. At the time of the incident, both protective end-caps on the bedframe were missing, exposing rough metal edges. Observations confirmed that the mattress cover above the uncapped area was also torn, indicating the hazard had been present for some time. Interviews with staff and the resident's family revealed that the missing end-caps were not an isolated issue; several other beds in the facility were also found to be missing the same protective pieces during subsequent safety checks. The Maintenance Director and Assistant confirmed that the end-caps were replaced only after the injury occurred, and there was no ongoing plan for regular monitoring of bed safety at the time of the incident. The facility lacked a specific policy addressing environmental hazards, and the existing maintenance policy only required semi-annual checks, which did not include routine inspection for missing bedframe end-caps. The injured resident had a history of dementia, repeated falls, and skin tears, and resided in a secured memory care unit. Previous care plans and progress notes indicated ongoing issues with skin injuries, but lacked documentation on the causes or follow-up for these incidents. Despite care plan interventions to keep the environment free from hazards and observe for potential causes of skin trauma, the hazardous condition of the bedframe was not identified or addressed prior to the resident's injury.