Failure to Maintain Beds With Proper Footboards and Safe Hardware
Penalty
Summary
The facility failed to maintain resident beds in safe operating condition by not ensuring that two beds on Hall 100 had footboards properly installed. For one resident, a female with high blood pressure and Alzheimer's disease who was newly admitted to room [ROOM NUMBER] A, surveyors first observed the bed unoccupied and missing both the footboard and the brackets needed to attach it, with visible holes in the frame where brackets should be mounted. Later the same day, the resident was observed in this same bed, which remained without a footboard, although it was in the lowest position. For another resident, a female with heart disease, muscle weakness, a history of falls, and a documented moderate fall risk, surveyors observed her bed in room [ROOM NUMBER] A to be missing the footboard but equipped with metal brackets that extended approximately two to three inches beyond the mattress. The resident, who had no impaired cognition and a BIMS score of 13, reported she had not hurt herself on the metal and had not reported the issue. Staff interviews revealed that a Laundry/Housekeeping Supervisor had seen a new footboard in storage but was unaware it was needed, and the Maintenance Supervisor stated that no one had reported the missing footboards in the electronic reporting system. The facility had a written policy requiring regular inspections of all bed frames and for the Maintenance Director to follow manufacturers' recommendations and establish a maintenance and inspection schedule.
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