Failure to Lock Bed Wheels During Resident Care
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to lock the bed wheels of an 81-year-old female resident before raising her bed, performing peri-care, and repositioning her in bed. The resident, who had a history of hemiplegia, hemiparesis, generalized muscle weakness, osteoarthritis, dementia, and aphasia, was completely dependent on staff for all activities of daily living, including transfers and toileting. The care plan for this resident identified her as being at risk for falls and required adherence to the facility's fall protocol. During an observed episode of care, the CNAs unlocked the bed wheels to move the bed away from the wall and then proceeded to raise the bed and provide incontinent care without relocking the wheels. While turning the resident from side to side and repositioning her using a draw sheet, the bed remained unlocked and moved gently as the care was provided. Both CNAs later acknowledged during interviews that they had forgotten to lock the bed wheels and recognized that this was not in accordance with safety protocols. Interviews with the Director of Nursing (DON), a Licensed Vocational Nurse (LVN), and the facility Administrator confirmed that staff are expected to lock bed wheels before providing care or repositioning any resident in bed. The facility's policy on routine resident care also states that equipment with wheels should be in the locked position when not being moved. The failure to lock the bed wheels during care constituted a deficiency in maintaining a resident environment free from accident hazards and providing adequate supervision to prevent accidents.