Failure to Maintain Safe and Functional Bed Equipment for Resident
Penalty
Summary
The facility failed to ensure that all patient care equipment was in safe operating condition for one resident with multiple medical conditions, including Parkinson's disease, hypertension, type 2 diabetes, anxiety disorder, muscle weakness, and lack of coordination. The resident, who had moderate cognitive impairment, was found lying flat in bed and unable to use the bed remote control to elevate the head of the bed as ordered by his primary care provider. The resident reported being unable to eat or sleep since the previous evening due to the malfunctioning bed, and staff observations confirmed that the bed remote was not working. The bed was also noted to be in the highest position, and the resident refused care because of the broken bed. Staff interviews revealed that while the issue was reported by the midnight nurse and logged in the electronic maintenance system by the morning nurse, the Assistant Director of Nursing (ADON), Maintenance Director, and Clinical Services Director were not aware of the problem until the morning. The Maintenance Director stated that staff should have moved the resident to a functioning bed and reported the issue directly to him. The facility's policy required the interdisciplinary team to assess the resident's sleeping environment for safety and comfort, but this was not followed, resulting in the resident being left in an unsafe and uncomfortable position for an extended period.