Failure to Maintain Bed Footboards in Safe, Homelike Condition
Penalty
Summary
The facility failed to maintain bed footboards in good repair in a shared room occupied by two residents, resulting in exposed, rough particle board surfaces on both beds. During observation, one resident’s footboard was missing banding, leaving a 3–4 inch rough area of exposed particle board, while the other resident’s footboard had multiple damaged areas, each about 6 inches long, where the laminate covering was missing and particle board was exposed. Review of the facility’s online maintenance work order system over an approximately one-year period showed no documented requests for repair of these bed footboards. A nurse aide reported that the outer coating on one resident’s footboard had been missing for some time, exposing rough particle board, and confirmed that both footboards had exposed particle board, but she had not notified any staff members. An agency nurse stated she had observed damage to the outer coating of both residents’ footboards a couple of weeks earlier but assumed Maintenance was already aware and did not report it. The Maintenance Director, who had been employed since the previous April, stated he was unaware of the damage until notified by the Administrator and that staff were expected to submit work orders when beds were in disrepair. The DON and Administrator both stated they were not aware of any damage to the footboards until it was brought to their attention during the survey, despite nursing staff having access to a system to request maintenance concerns at all times.
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