Failure to Maintain Bed Hardware Safely, Resulting in Resident Skin Tear
Penalty
Summary
The facility failed to ensure a resident’s bed was free from accident hazards when a bed was used without required plastic protective pieces on the metal frame. The resident involved had multiple diagnoses, including rheumatoid arthritis, chronic kidney disease, congestive heart failure, and several pressure ulcers, and had an ADL care plan indicating impaired mobility, pain, and a need for staff assistance with transfers. After providing a shower, a CNA transferred the resident back to bed and observed redness on the resident’s left lower leg. The CNA inspected both the shower chair and the bed and noted that square pieces in the middle of the bed frame were missing plastic protective covers. A subsequent Skin Alteration Nursing Evaluation documented a rear left lower leg skin tear for the resident later that same day. During a care plan meeting, the resident’s daughter reported that there were missing pieces on the bed and that the resident had scratched her leg on the bed. The Admissions Director acknowledged hearing from the Social Services Director that a resident’s bed needed to be replaced due to missing plastic protective pieces, and the Maintenance Assistant confirmed that two plastic protective pieces were missing from the center of the bed frame, leaving exposed metal squares. The Administrator stated that a resident’s bed should have all required pieces to ensure resident safety, confirming that the bed in use for this resident did not meet that standard at the time of the incident.
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