Failure to Ensure Enclosure Bed Safety Results in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with a history of neurocognitive disorder, epileptic seizures, and traumatic brain injury, who was identified as high risk for falls, experienced a fall from an enclosure bed. The enclosure bed, designed with mesh walls and a zipper to prevent falls, failed to provide adequate protection when the net zipper malfunctioned or was not properly secured. Staff had previously observed the resident inspecting and attempting to manipulate the zipper while inside the bed. On the day of the incident, the resident was found on the floor after managing to open the zipper, either due to a malfunction or because it was not properly secured by staff. Record reviews and staff interviews revealed that the resident was on 15-minute supervision for safety at the time of the unwitnessed fall. Facility policy required nursing staff to ensure all zippers were secure and clipped during rounds, whether the bed was occupied or unoccupied. However, staff did not ensure the enclosure bed was properly secured or in good working condition, which contributed to the resident's ability to open the bed and fall.