Failure to Accommodate Resident Needs During Bed Rail Installation
Penalty
Summary
A deficiency occurred when a resident with a left tibia fracture and chronic pain syndrome was left lying in bed while maintenance staff installed metal side rails using a power drill. Despite the resident's request to be removed from bed and placed in a wheelchair due to pain, maintenance continued drilling for approximately 15 minutes, causing the bed to shake and resulting in severe pain for the resident. The resident reported crying and experiencing significant discomfort during the incident. The resident was cognitively intact, as indicated by a BIMS score of 14, and had a full support brace on the affected leg. The maintenance staff stated that the installation was ordered by the DON and confirmed that the procedure was performed while the resident remained in bed. The DON acknowledged that maintenance should have stopped if the resident complained of pain. Facility policy states that residents have freedom of choice regarding their care, but this was not accommodated during the event.