Failure to Maintain Functioning Bed Equipment for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a dependent resident’s bed was functioning to meet his needs. The resident had multiple significant diagnoses, including cerebral infarction, Type 2 DM, quadriplegia, protein-calorie malnutrition, polyneuropathy, fusion of spine, cerebral atherosclerosis, and cervical disc disorder with myelopathy. His facility assessment showed no cognitive impairment and dependence on staff for most care. His care plan documented a self-care deficit in bed mobility related to his conditions, requiring a two-person assist with bed mobility and use of bilateral half rails to promote bed mobility, and noted he required assistance with daily care needs with monitoring for changes and adjustment of assistance as needed. A CNA reported that most beds were broken in some way and specifically stated that this resident’s bed was “always broke” and that he could not raise the head of the bed when he wanted to eat. During observation, the resident was found lying in bed with the head of the bed flat while watching television. He stated that his bed had not been working for a long time, that he had informed staff, and that although maintenance had previously worked on it, it would only function for a short period before failing again. He reported that he preferred to sit up, could sit up on his own but with difficulty due to his prior stroke, and wanted to use the bed remote to raise the head of the bed, especially for eating, which he always did in his room. He said the bed had not been working for about a month and a half on this occasion. When the Maintenance Director inspected the bed, he stated he had not been aware the bed was not working, found the power cord pulled out of the box under the bed with the clip missing, and noted they had no extra beds but used parts from other beds for repairs. Review of the maintenance binder and prior maintenance logs showed no recorded maintenance requests for this resident’s bed during the relevant period. The DON stated that if staff noted a broken bed, she would expect it to be reported to maintenance and fixed, acknowledged the importance of the resident’s equipment functioning, and described the resident’s abilities and prior attempts to sit up or get up on his own.
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