Resident Neglect Due to Unsafe Bed Positioning
Penalty
Summary
Chapel Manor was found to be non-compliant with the requirement to ensure residents are free from neglect, as outlined in 42 CFR Part 483, Subpart B. The deficiency was identified following an incident involving a resident, who was left in an unsafe position after receiving care. The resident, who had severe cognitive impairment and was at risk for falls, was left in a bed that was not lowered to a safe position, resulting in a fall that caused significant injuries. The resident, admitted with conditions including COPD, osteoporosis, and dementia, was assessed as having a high risk of falls. The care plan specified that the resident's bed should be kept in the lowest position to prevent falls. However, after morning care, a nurse aide left the resident's bed in a raised position while retrieving a wheelchair, during which time the resident rolled out of bed, sustaining a subdural hematoma and a fracture of the left femur. Interviews with staff confirmed that the bed was left in a high position contrary to the care plan's instructions. The Director of Nursing acknowledged that the bed should have been lowered to prevent such incidents. The facility's failure to adhere to the care plan and ensure the resident's safety resulted in actual harm, highlighting a lapse in following established safety protocols.
Plan Of Correction
The facility cannot retroactively correct the cited deficient practice. An initial observation of care will be conducted of 5 residents receiving care on each shift to verify residents' beds are placed in a safe position after the completion of care. The NPE or designee will re-inservice nursing staff on the Safe Resident Handling policy with the focus on placing residents' beds in a safe position after the completion of care. The NPE or designee will re-inservice nursing staff on the Abuse policy. The DON or designee will conduct random observations of 5 residents receiving care weekly x 4, then monthly x 2 to verify residents' beds are placed in a safe position after the completion of care. Results of the audits will be presented at the QAPI meetings for review. Date of compliance May 6, 2025