Resident Injured by Exposed Bedframe Components During Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe bedframe and environment free from accident hazards for a dependent, bedbound resident, resulting in actual harm. The resident had acute and chronic respiratory failure, anoxic brain damage, tracheostomy status, generalized muscle weakness, and was dependent on staff for bed mobility per the most recent MDS. The care plan indicated the resident required one-person assistance for bed mobility. During early morning incontinence care, a CNA turned the resident onto the left side and, after 30–40 seconds, turned the resident back and observed blood streaming from the eyebrow area, with blood noted on the wooden and metal parts of the headboard and bedframe. Clinical assessments documented two lacerations to the forehead above the eyes, swelling and bruising to the left eye, and a small cut inside the mouth, with blood in the oral cavity and discoloration and inflammation of the left eye. The resident was described as tracheostomy-dependent, bedbound, alert but not oriented, and requiring one-person assistance for bed mobility and incontinence care. The resident was transferred to the hospital via EMS after the injuries were identified, and the responsible party was notified. Staff statements consistently linked the onset of bleeding and visible injuries to the period immediately following repositioning for incontinence care. Investigation and observation identified exposed structural components of the bedframe as the likely source of injury. The DON reported that the resident’s facial injuries were believed to have occurred when the resident’s face contacted an exposed pin used to secure two pieces of the bedframe, with the sharp ends causing the lacerations as the resident was repositioned onto the back. The DON further believed that the black eye and forehead swelling were caused by contact with an exposed knob on the frame. Observation of the bedframe showed an exposed pin securing the connection between the base and headboard, located approximately two inches below the top of the deflated air mattress; the DON confirmed the mattress was inflated when in use and explained that the resident’s contractures caused a “boomerang” body shape, resulting in the head and feet overlapping the mattress edge during side positioning, and that the resident’s spine had not been aligned with the bed edge nearest the CNA at the time of the incident.
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