Malfunctioning Bed Rails Not Maintained in Safe Working Order
Penalty
Summary
The facility failed to ensure that a resident’s bed rails were safe, functional, and in good working condition in accordance with its policies. The resident had diagnoses including lack of coordination and abnormalities of gait and mobility, and an MDS assessment documented severe cognitive impairment and a need for partial/moderate assistance with bed mobility, transfers, and sit-to-stand activities. A physician’s order authorized bilateral 1/3 bed rails as an enabler to aid in mobility, positioning, and transfer. During observation, the resident was found lying in bed asleep with both 1/3 bilateral bed rails in the raised position. When checked by a Licensed Vocational Nurse, both bed rails were found to be stuck and could not be lowered, contrary to the expectation that they should lower easily to allow the resident to get in and out of bed safely. A Maintenance Assistant subsequently examined the bed rails, removed and reinstalled them, and was still unable to lower the left bed rail. The Maintenance Assistant stated that the bed rails on this type of bed were not working properly, despite being reinstalled in the correct holes. A CNA reported that bed rails should be working properly because staff raise and lower them when changing and positioning residents. The DON stated that residents’ beds should be in good working order for residents’ safety and ease of use. Review of the facility’s Maintenance Service policy indicated that the maintenance department is responsible for maintaining equipment in a safe and operable manner at all times, and the Bed Safety and Bed Rails policy required that any worn or malfunctioning bed system components be repaired or replaced using components that meet manufacturer specifications. These observations and statements showed that the resident’s bed rails were malfunctioning and not maintained in accordance with facility policy.
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