Failure to Provide Appropriate Bariatric Beds and Supervision Resulting in Resident Injuries
Penalty
Summary
The facility failed to provide sufficient supervision, prevent avoidable accidents, follow appropriate safety procedures, and utilize the required number of staff during care for two residents who required bariatric beds and mattresses. In the first case, a resident with significant mobility impairments and a history of cerebral infarction, heart failure, and recent fractures was being provided incontinent care by a single aide. The resident was instructed to roll over and subsequently fell from the bed, resulting in multiple fractures. It was found that the mattress in use was too large for the bed frame, and staff had previously switched to a smaller bed frame without ensuring compatibility with the bariatric mattress. The care plan indicated the resident required maximum assistance and two staff for transfers, but this was not followed during the incident. In the second case, another resident with chronic respiratory failure, morbid obesity, and muscle weakness, who required substantial assistance with mobility and was at high risk for falls, was found on the floor with the mattress over them after turning in bed. This resident was using a standard mattress and bed despite documented requirements for a bariatric mattress and bed due to their height and weight. Staff interviews and documentation confirmed that the need for a bariatric mattress was communicated prior to admission, but the resident was not provided with the appropriate equipment at the time of the fall. The resident sustained acute fractures as a result of the incident. In both cases, there was a breakdown in communication and execution of safety protocols regarding the provision of appropriate beds and mattresses for residents with bariatric needs. Staff failed to ensure that the correct equipment was in place and did not follow established procedures for safe resident handling and supervision, directly leading to serious injuries for both residents.