Failure to Provide Ordered Side Rails Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate goods and services to prevent falls, resulting in neglect of a resident who required partial to moderate assistance with bed mobility. The resident had significant medical diagnoses, including respiratory failure, heart failure, and diabetes, and was assessed as needing help to roll in bed. Despite a physician's order for bilateral side rails, the resident's care plan did not include the use of side rails, and they were not present on the bed at the time of the incident. During care, a nurse aide was repositioning the resident in bed without the use of side rails, and the bed was in a high position. The resident rolled out of bed and sustained a head injury, including a minimally depressed right orbital floor fracture, requiring transfer to the hospital. Interviews and documentation confirmed that the resident had previously requested side rails and reported prior falls from bed, but no new interventions were implemented. Staff interviews revealed confusion about the process and timeliness for installing side rails after an order was placed, with delays attributed to maintenance procedures. Observations after the incident showed the resident with visible injuries and without side rails on the bed. Multiple staff members, including nurse aides, LPNs, and the occupational therapist, acknowledged that side rails should have been installed promptly following the physician's order. The Director of Nursing confirmed that the facility failed to provide necessary goods and services to prevent the fall, resulting in actual harm to the resident.