Failure to Maintain Resident Bed in Safe Working Condition
Penalty
Summary
A resident’s right to a safe, clean, comfortable, and homelike environment was not honored when the facility failed to maintain the resident’s bed in safe working condition. Surveyors observed that the cognitively intact resident, who was dependent on staff for transfers, was in a semi-private room in a bed positioned above its lowest setting with the head of the bed elevated. The bed was unplugged, and electrical wiring was hanging beneath it, including multiple visible internal wires and a gold-colored exposed wire that appeared damaged and not properly secured to the bed frame. The facility’s maintenance work order log contained no documentation of any work order for this bed during the review period. The resident reported that the bed had not been functioning properly for several months, that she had informed the Maintenance Director, and that maintenance staff had come to look at the bed several times but never completed repairs. She stated the bed remote did not work, she could not independently adjust or move the bed, and the bed remained partially elevated in a sitting position, causing back soreness, discomfort, and difficulty sleeping. Staff interviews revealed that the NA who typically cared for the resident observed the bed in a high position, a frayed electrical cord, and a missing “down” button on the remote, which prevented lowering the bed, but she had not previously noticed that the bed would not lower and reported the resident had not voiced concerns to her. The housekeeper who routinely cleaned the room stated she had not previously noticed concerns but, upon observation, saw the broken remote and inability to lower the bed. The Maintenance Director, who stated he was unaware of any concerns before the surveyor’s inquiry, observed exposed wiring beneath the bed and exposed internal wiring on the damaged remote and stated that pressing the damaged button posed a potential risk of electrical shock. The Administrator stated her expectation was that staff promptly identify and report maintenance concerns and ensure resident equipment is maintained in safe working condition.
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