Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with dementia, a history of falls, and osteoporosis, who required substantial assistance with bed mobility, was directed by a nursing assistant to turn onto their side in bed and grab the side-rail. The side-rail, which was intended to assist with bed mobility, was not locked into place at the time. As the resident grabbed the side-rail and applied pressure, it lowered unexpectedly, causing the resident to fall out of bed and sustain a head laceration and bruising to the knees and lower leg. The resident's care plan and kardex specified the use of padded side-rails and staff assistance for bed mobility, with the expectation that side-rails would be locked before use. During the incident, the nursing assistant had previously lowered the side-rail to change the bed linens and raised it again but failed to ensure it was securely locked. When the resident reached for the side-rail as instructed, the unlocked rail gave way, resulting in the fall and subsequent injuries. Interviews with facility staff confirmed that the expectation was for side-rails to be locked before providing care to residents who use them for mobility. The nursing assistant involved acknowledged not verifying that the side-rail was locked after raising it. Maintenance staff inspected all beds and found no mechanical issues with the side-rails, and staff education materials indicated that proper use and locking of side-rails were part of both initial and annual training.