Resident Fall Due to Inadequate Supervision and Bed Positioning
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls was not safely positioned in bed during morning care. The resident required substantial to maximal assistance for mobility and was dependent on staff for all care, including the use of a mechanical lift for transfers. On the morning of the incident, a CNA raised the resident's bed to a high position for body mechanics and was providing care alone. While attempting to place a mechanical lift sling under the resident, the CNA moved to the opposite side of the bed, leaving the resident facing the open side without supervision or protective barriers such as side rails or a fall mat in place. During this time, the resident moved her legs and rolled off the bed, falling onto the concrete floor and sustaining a scalp laceration that required staples. The incident report and staff interviews confirmed that the bed was elevated, the resident was left unsupervised on the open side, and the fall mat was not properly positioned. The facility's own fall risk management policy identifies incorrect bed height and cognitive impairment as risk factors for falls, both of which were present at the time of the incident.