Failure to Lock Bed Wheels During Repositioning Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident care area was free from accident hazards and that adequate supervision and safety practices were used during resident care, specifically by not locking the bed wheels before repositioning a resident. According to a nursing progress note, a CNA reported that while providing care, they rolled the resident toward themselves, but the bed was in a high position with the wheels unlocked and rolled backward, causing the resident to fall from the bed to the floor. The resident was found on the floor next to the bed in a curled position leaning toward the right side, with a hematoma to the forehead, a skin tear on the left deltoid, and a skin tear on the right elbow, and complained of pain to the left foot. The facility’s post-fall analysis and investigation documented that staff rolled the resident toward themselves and the bed rolled away due to unlocked wheels, which was identified as the root cause of the fall. A written statement from the CNA confirmed that while performing care and rolling the resident from the wall side toward their body, the bed slid and the resident fell onto her side, resulting in bruising to the head, arm, and leg. Hospital imaging and assessment documented a closed displaced fracture of the left tibia, a contusion of the left upper extremity, and an abrasion of the right upper extremity, with the resident made non–weight bearing on the left lower extremity. The facility’s Resident Safety and Precautions policy in effect at the time required that bed wheels be locked as part of resident safety standards, which was not followed in this incident.
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