Improper Bed Rail Installation Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that bed rails were properly installed and maintained, resulting in actual harm to a resident. The resident, who had multiple complex medical conditions including a recent traumatic amputation, diabetes with polyneuropathy, COPD, pulmonary hypertension, and an activities of daily living (ADL) self-care deficit, required maximum assistance from staff for bed mobility and personal care. Documentation indicated that the resident expressed a desire for bed rails to assist with autonomy, and bilateral bed rails were provided. However, the Minimum Data Set assessment did not indicate bed rail use, and there was no evidence that the bed rails were consistently or correctly installed according to manufacturer instructions. On the day of the incident, three staff members were providing in-bed care when the resident was rolled to the side and the bed rail detached from the bed frame. The staff attempted to lower the resident to the floor, but the resident sustained a displaced fracture of the right humeral neck. Staff statements and interviews confirmed that the resident was holding onto the bed rail when it broke off, and that the bed rail had been previously reported as loose and had been moved to an insecure location on the bed frame. The Maintenance Director confirmed that the bed rails were not compatible with the crossbar where they had been attached, and that staff had previously adjusted and installed the bed rails incorrectly. The facility did not have the correct user manual for the bed rails in use, and the manual provided to surveyors did not match the equipment used. Facility policy required that bed rails be installed and maintained according to manufacturer specifications, including ensuring compatibility with the bed and mattress, and regular inspection for secure installation. Despite these requirements, the bed rails were not properly installed or maintained, and staff were not able to identify who had moved or adjusted the rails prior to the incident. This failure directly resulted in the resident's fall and injury during routine care.