Failure to Maintain Safe Bed Rail and Wheelchair Equipment for Two Residents
Penalty
Summary
The facility failed to maintain resident equipment in safe working order for two cognitively intact residents. One resident, admitted with chronic respiratory failure, venous insufficiency, lymphedema, morbid obesity, fluid overload, cellulitis of the right lower limb, bed confinement, and a stage 4 sacral pressure injury, reported that the right siderail on his bed was loose. During observation, the siderail moved side to side when the resident manipulated it, and he stated he needed the siderails to roll from side to side. He reported having notified the facility about this problem about a week earlier, but it had not been fixed at the time of the surveyor’s observation. Another resident, admitted with type II DM, chronic kidney disease, anemia, restless legs syndrome, adjustment insomnia, glaucoma, and an acquired absence of the right leg below the knee, reported waiting for maintenance to fix the right armrest on his wheelchair. Observation showed the right armrest’s cushioned piece was hanging off the back by about 5–6 inches, exposing metal underneath, and the resident had a scrape on his right forearm, which he attributed to using his arms to propel the wheelchair. The left armrest lacked a cushioned piece. The resident stated he had reported this concern a couple of weeks earlier. The Maintenance Director stated the facility does not use work orders or track when repairs are requested or completed, acknowledged awareness of the loose siderail and the armrest concern, and indicated he was waiting for a replacement armrest. The facility’s Preventative Maintenance Program Policy requires that resident equipment, including bed rails, be in working order during environmental and safety audits.
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