Failure to Maintain Safe Environment Due to Malfunctioning Bed Brakes
Penalty
Summary
A deficiency occurred when the facility failed to maintain a safe environment free from accident hazards for a resident admitted with unsteadiness on feet and a traumatic brain injury. The resident experienced two falls on the day of admission, and a subsequent unwitnessed fall occurred when the resident rolled out of bed due to malfunctioning bed brakes. Although the baseline care plan included interventions such as a PT consultation and monitoring for changes in condition, the bed brakes in the resident's room were not functioning properly at the time of the fall. Maintenance staff stated that bed brakes were supposed to be checked monthly, but there was no documentation to verify these checks or any work orders related to the malfunctioning brakes during the relevant period. Nursing staff confirmed the bed brakes were not working at the time of the incident, and the DNS stated that staff were expected to check bed brakes before leaving a resident's room.