Failure to Lock Bed for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when a resident, who was assessed as high risk for falls due to severe cognitive impairment, muscle weakness, osteoarthritis, osteoporosis, and poor safety awareness, experienced a fall. The resident's care plan specifically required that the bed be kept in a locked position to reduce the risk of injury from falls. However, during an observation, it was found that the bed was not locked and could be moved easily, which was confirmed by nursing staff. The resident had previously fallen when attempting to get up from the bed, and staff interviews confirmed that the bed should always be locked to prevent such incidents. Record reviews, including the resident's Minimum Data Set and Morse Fall Assessment, indicated a high risk for falls and dependence on staff for most activities of daily living. Facility policies on safety and fall risk management emphasized the importance of identifying and implementing interventions tailored to each resident's specific risks, including keeping beds locked for those at risk of falling. Despite these policies and the resident's care plan, the failure to keep the bed locked directly contributed to the resident's fall.