Facility I.D. Number0038653
Date of Survey 4/18/00
All necessary precautions shall be taken to assure that the residents environment remains as free of accident hazards as possible. All nursing personnel shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents.
An owner, licensee, administrator, employee or agent of a facility shall not neglect a resident.
These regulations are not met as evidenced by:
Based on observation, record review and interviews, the facility failed to properly fit a residents mattress and side rail. R1 fell between the bed frame and side rail of her bed sustaining an injury to the left eye requiring an enucleation.
R1's record reads that at 5:30 A.M. on 3-19-00 `Resident was found on her (L) side wedged between the bed and side rails. Face was against the side rails, lg. amt. of bleeding noted from (L) eye side rails was taken off the bed and pt. was lower to the floor. Clean dry dressing applied to (L) eye'
Surveyors interviewed E1 at 9:00 A.M. on 4-7-00 in the facility's conference room. E1 stated she turned R1 on her left side at 3:00 A.M. and at that time R1 was " O.K." At 5:15 A.M. she went into R1's room to get R1 up. E1 stated R1 was caught between the side rail and the bed. E1 said there was very little bleeding at that time.
E1 said she called for help because she realized that she could not get R1 up by herself. E1 stated to surveyors that in the past she had reported some side rails being too far from the bed. She said she reported this to the maintenance department and she said that she had written up maintenance slips.
Surveyors interviewed E2 at 10:00 A.M. on 4-7-00 in the facility's conference room. E2 said that on the morning of the incident she was sitting at the nurses station at 5:00 A.M. getting report. E1 hollered for help at about 5:15 to 5:30 A.M. E2 said when she entered R1's room, she saw R1 between the mattress and the side rail. E2 said she saw the side rail in R1's eye. E2 said she saw the blood on the floor and on R1's face. E2 said she went to hold R1's head and she could see the end of the rail in R1's eye. E2 said that R1 was lying more on her back than on her side. E2 told surveyors that she had told staff about the residents mattresses being too far from the side rails and that she sometimes stuffed pillows or blankets between to fill up the holes. E2 said she does not recall which staff she told.
Surveyor interviewed E7 at 9:50 A.M. on 4-7-00 at the 100-200 wing nurses station. E7 said, " We all have had concerns about mattresses being too far from side rails. We asked (E4) why did we get these? We were told that's just the way they are."
Surveyors interviewed E5 at 8:35 A.M. on 4-7-00 in the facilities conference room. E5 admitted to surveyors that the facility had been experiencing problems with newly received side rails not fitting securely against bed mattresses. E5 said these new side rails expand in such a way as to allow for at least a 5 inch gap if the residents mattress slid to one side of the bed. E5 said that since the incident of R1, facility maintenance has been bolting these side rails to the bed frames to prevent such slippage.
On 4-7-00, surveyors viewed the bed in which R1 was injured. The side rails were observed to be flush against the mattress because the facilities maintenance department had already bolted the slipping side rails to the bed frame.
Next, surveyors were shown a bed with side rails identical to the one used by R1. These side rails had not yet been bolted to the bed frame. When the mattress of this bed was shifted next to the right bed rail, surveyors noted an approximate 7-8 inch space occurring between the mattress and the left side rail. E1 laid in this space and demonstrated the wedged position in which she found R1 the morning of 3-19-00. Additionally, during inspection of these side rails, surveyor noted a plastic safety cap which should have covered the end of a metal tubular frame on the right side of the bed to be missing. Surveyors discussed with E4 and E5 whether or not R1's bed frame had a protective cap on the end of the tubular frame where R1 had been injured. Both stated they did not know.
Surveyors returned to the bed where R1 was injured and removed the plastic cap that covered the tubular metal frame to find dried brownish-red matter resembling dried blood on the inside of the plastic cap.