Failure to Maintain Resident Bed in Safe Operating Condition
Penalty
Summary
The facility failed to maintain a resident’s bed in safe operating condition, resulting in a persistently uneven, left-tilting bed over multiple days. Facility policy on providing a safe and homelike environment required staff to report any furniture in disrepair to maintenance promptly. Resident #142, admitted with diagnoses including unspecified dementia, osteoarthritis, and intervertebral disc displacement of the lumbar region, had a care plan identifying potential for falls with injury related to non-compliance with safety measures and specifying use of a concave mattress and other safety interventions. Despite this, surveyors observed on four separate dates that the resident’s bed was visibly uneven with a noticeable left-sided downward tilt. Resident #142 reported that the bed had been broken for a long time, had informed family and facility staff, and expressed fear of falling because the bed was lopsided, although no fall had occurred. When an LPN acting as unit manager operated the bed controls, he confirmed the bed was not even, with the right side higher and tilting to the left, and stated it was the first time he was aware of the issue. The Maintenance Director later examined the bed, stated the bed frame was broken, and could not recall the last time an audit had been done for the resident’s room. The Administrator stated that the expectation was for the Maintenance Director to follow policy and perform routine maintenance, and reported having no prior knowledge that the bed was broken.
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