Resident Injury Due to Exposed Bed Frame Hazard
Penalty
Summary
A resident with a diagnosis of senile degeneration of the brain, dementia, and anxiety disorder experienced a significant injury due to a failure by the facility to maintain the resident's bed in a safe condition. During a transfer from wheelchair to bed, assisted by a CNA as per the resident's care plan, the resident sustained a large laceration on the right lateral leg. The injury occurred when the resident's leg came into contact with an exposed area of the bed frame, specifically where a round cap was missing. The wound was severe, requiring emergency room evaluation and 12 sutures, and was accompanied by moderate bleeding and drainage. Staff interviews and record reviews confirmed that the missing bed cap had not been previously identified or reported, and the facility did not have documentation of routine checks to ensure resident beds were free from hazards. The maintenance director only became aware of the missing cap after the incident and replaced it at that time. The absence of a policy or documented procedure for regular inspection of beds contributed to the presence of the hazard that led to the resident's injury.