F0689

G

Failure to Lock Beds and Provide Required Two-Person Assistance During Bed Mobility Resulting in Falls and Fractures

Hamburg, New York Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and use of assistive devices during resident repositioning and bed mobility, resulting in falls and fractures for two residents. Facility policy defined accidents and falls and required thorough assessment, appropriate interventions such as adequate supervision and assistive devices, and adherence to safety practices including locking bed systems. The bed manufacturer’s user manual also warned that the Care-Lock feature should be locked at all times except when moving the bed and that an unlocked bed should never be left unattended. Despite these requirements, staff provided care with beds unlocked and without the required number of assisting staff, leading to residents falling between the bed and the wall.

For the first resident, who had a right below-knee amputation, diabetes mellitus, and muscle weakness, the MDS and care plan documented that the resident was cognitively intact and required substantial/maximal assistance of two staff for rolling left and right in bed. The Kardex also specified two-person assistance for bed mobility. On the evening of the incident, the resident was being provided personal care when a CNA instructed the resident to roll toward the wall. Statements and interviews indicated that only one CNA was actively rolling the resident, the second CNA was at the foot of the bed rather than positioned on the opposite side, and the bed was not locked. As the resident rolled toward the wall, the unlocked bed moved away, and the resident slid or fell between the bed and the wall, striking the wall and floor. The resident reported that the CNA forcefully rolled them using the draw sheet, that their right hand hit the wall, and that the bed rolled away, causing them to fall and hit their head.

Following this fall, the resident complained of pain in the right shoulder, knee, and elbow. Initial x-rays of the right elbow were documented as normal, but the resident continued to report right arm and elbow pain. Subsequent imaging later identified a fracture involving the radial head/neck of the right elbow, and an orthopedic consult diagnosed a nondisplaced radial head fracture. Therapy documentation noted that the resident’s rehabilitation was complicated by the elbow fracture, which required non-weight-bearing status of the right upper extremity and affected functional mobility. Multiple staff interviews, including with the PA, DON, nurse educator, LPNs, physical therapist, and medical director, consistently described that the bed was not locked, that the resident required two-person assistance for bed mobility, and that only one CNA was in proper position to roll the resident at the time of the fall.

For the second resident, who had COPD, type 2 diabetes mellitus, depression, and lower extremity impairments, the MDS and care plan documented that the resident was cognitively intact, required maximum assist of two staff for bed mobility to turn right and left, and was at risk for falls. The Kardex documented dependence on two or more staff to roll left and right in bed. During early morning care, a CNA was dressing the resident and rolled the resident toward the wall to pull down the shirt and place a sling under them. The CNA reported that the resident put a hand on the wall for support and that the bed began to move away from the wall. The CNA attempted to hold the resident but was unable to prevent the resident from falling between the bed and the wall. The incident report documented that this was a witnessed fall out of bed during care, resulting in lacerations to the back of the head, right elbow, and right eyebrow.

After this fall, the resident was sent to the hospital, where records documented a head injury and laceration repair to the forehead. Upon return, the resident complained of facial pain and left hand pain; assessment revealed swelling, bruising, and pain with range of motion of the left middle finger. An x-ray showed a comminuted nondisplaced fracture of the third metacarpal of the left hand. Interviews with supervisory nursing and rehabilitation staff indicated that the resident required one assist for dressing but two staff for bed mobility at the time, and that the resident fell when rolled toward the wall during care. Staff and leadership acknowledged uncertainty about whether the bed was locked but described the resident as found between the bed and the wall and characterized the event as a failure to follow the care plan and to ensure the bed was secured during care.