Failure to Maintain Safe Bed Heights for High Fall Risk Residents
Penalty
Summary
The facility failed to ensure that resident beds were maintained at a safe height, resulting in accident hazards for two residents identified as high risk for falls. In one instance, a resident with a history of cerebral infarction, hypertension, and muscle wasting was found with both the bed and over bed table in a very high elevated position. The resident expressed concern about the bed's safety, and the Physical Therapy Assistant confirmed the bed should not have been left in that position, noting the increased risk of injury if a fall occurred. The resident's care plan indicated a risk for falls and included interventions to provide a safe environment. In another case, a resident with a displaced femur fracture, diabetes, vertebral fracture, and dementia was also found with the bed and over bed table in a high position. A CNA acknowledged leaving the bed elevated, despite the resident being identified as a high fall risk with a care plan intervention to provide a safe environment. The facility's policy required fall interventions for those at high risk, but these were not followed in these instances.