Failure to Lock Bed Brakes Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s bed wheels were locked, resulting in a fall from bed. The resident was a middle‑aged male with extensive medical and psychiatric diagnoses, including other seizures, epilepsy with status epilepticus, insomnia, obstructive sleep apnea, intellectual disability, generalized anxiety disorder, schizoaffective disorder bipolar type, persistent mood disorder, personality disorder, right above‑knee amputation, peripheral vascular disease, muscle wasting and atrophy of both upper arms, and a cognitive communication deficit. His care plan directed that his bed be kept in the lowest position with wheels locked, and identified that he had a behavior of self‑adjusting the bed height and keeping it high. The care plan also documented a history of an actual fall and a goal of no further fall‑related injuries. On the date of the incident, the resident fell out of bed and was found on the floor. Facility incident documentation and staff interviews confirmed that the bed wheels were not locked at the time of the fall. The resident was described as morbidly obese, an amputee, bedfast, and at least a two‑person assist for transfers, and his legal guardian stated he was fully dependent on the bed being in place and leaned on the wall for comfort. The resident reported that two nurses failed to lock his bed wheels, causing his fall. The legal guardian reported that he scraped his elbow and complained of pain after the fall. Emergency department records documented complaints of left hip and back pain, tenderness to palpation of the left hip and femur, intermittent agitation, and that he apparently rolled too far while sleeping on his left side, landing on his left side on the floor. Staff interviews revealed gaps in practice and knowledge related to bed wheel locking. An LVN stated that the wheels on the resident’s bed were not locked at the time of the fall and acknowledged that leaving bed wheels unlocked could result in a resident falling out of bed, but she was unaware of any facility policy on locking bed wheels. CNAs reported receiving training that included bed locks, and one CNA stated that the resident had a fall mat on one side of the bed but not on the wall side. The administrator confirmed that no staff were disciplined because responsibility for failing to lock the bed wheels could not be determined and also stated there was no facility policy related to bed wheels being locked. Surveyors concluded that the facility failed to provide adequate supervision and to maintain the environment free from accident hazards when the resident’s bed brakes were not locked, leading to the fall.
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