EL MONTE, CA - A resident at Sunset Manor Convalescent Hospital sustained a laceration requiring seven stitches after grabbing a broken bed remote control with exposed sharp edges, an incident that maintenance staff acknowledged could have been prevented through routine equipment inspections.
Equipment Failure Results in Hand Laceration
On December 17, 2024, a non-verbal resident with severely impaired cognition experienced a hand injury during what should have been a routine care interaction. The incident occurred when a Certified Nursing Assistant (CNA) was turning and repositioning the resident, who grabbed onto the facility's bed remote control. Unknown to staff, the outer plastic casing of the remote's coil line had broken away, leaving sharp edges and exposed internal wiring.
The resident, who was admitted in August 2024 with Type II diabetes, heart failure, and respiratory failure, was completely dependent on staff for all activities of daily living including transfers, dressing, and toileting. The laceration to the right palm, located between the thumb and index finger, required hospital transport and surgical repair with seven stitches at a local acute care facility.
According to the facility's maintenance assistant who investigated the incident, blood stains were found on the broken portion of the bed remote control coil, and the exposed inner wire created a sharp pointed edge where the hard plastic outer layer had peeled away.
Absence of Preventive Maintenance Protocol
The inspection revealed a critical gap in the facility's equipment safety program. The maintenance assistant reported that inspecting bed remote controls was not part of the department's routine tasks during the nine months prior to the incident. Instead, the maintenance department operated on a reactive basis, only checking equipment when problems were reported.
This reactive approach contradicts fundamental patient safety principles. Bed remote controls are high-touch medical devices that patients interact with multiple times daily. The plastic coatings on these devices degrade over time due to frequent handling, body oils, cleaning chemicals, and mechanical stress from the coiled cable design. Regular visual inspections can identify cracking, brittleness, or separation of protective coverings before they create hazardous conditions.
For residents with diabetes, even minor lacerations carry elevated risks. Diabetes compromises the body's wound-healing mechanisms by impairing immune response and reducing blood flow to extremities. What might be a superficial cut for a healthy individual can develop into a serious wound infection requiring extended antibiotic therapy or additional surgical intervention in diabetic patients.
Staff Acknowledge Preventable Injury
Multiple staff members recognized the failure in the facility's safety systems. The Licensed Vocational Nurse stated that staff needed to ensure equipment remained in good condition to prevent resident injuries, and that maintenance personnel should routinely check all devices to verify proper working condition. The maintenance assistant was direct in stating: "If the Maintenance Department performed a routine check and found the broken bed control coil line earlier, Resident 1's injury could have been prevented."
The facility's Director of Nursing acknowledged the systemic failure, stating that routinely checking all medical devices and maintaining them in good condition was essential for resident safety, and that this particular injury could have been avoided with proper equipment maintenance.
Industry Standards for Equipment Maintenance
Healthcare facilities are required to implement preventive maintenance programs that ensure a safe environment for residents. The facility's own policy, dated December 2022, specifically outlined this requirement, stating that "a preventive maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public."
The policy designated the maintenance director as responsible for "developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner." However, the inspection found that bed remote controls—devices in constant contact with residents—were excluded from routine inspection schedules until after this injury occurred.
Standard practice in healthcare settings involves scheduled inspection cycles for all patient-contact equipment. Visual inspections of bed controls, call systems, and similar devices should occur during routine room cleaning or monthly equipment checks. Damaged items should be immediately removed from service and replaced, not left in patient rooms where they pose injury risks.
Additional Issues Identified
The inspection documented that routine equipment safety checks were only added to the maintenance department's responsibilities following this December incident, representing a nine-month gap in preventive safety measures since the maintenance assistant's hire date.
Facility Response
Following the injury, the facility modified its maintenance protocols to include bed remote controls in routine inspection schedules. However, this change came only after a vulnerable resident with multiple chronic conditions required surgical intervention for an injury that staff across multiple departments acknowledged was preventable through basic equipment safety measures.
The incident highlights how gaps between written policies and actual implementation can directly impact resident safety, particularly for those who cannot verbally report equipment problems or protect themselves from environmental hazards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunset Manor Conv Hosp from 2025-01-03 including all violations, facility responses, and corrective action plans.
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