Failure to Implement Bed Border Intervention for Fall Prevention
Penalty
Summary
A deficiency was identified when the facility failed to implement a care plan intervention for a resident at risk for falls. The resident, who had diagnoses including COPD, dementia, osteoarthritis, difficulty in walking, and a history of falls, was assessed as having severe cognitive impairment. The care plan included an intervention to define the borders of the bed to prevent falls, such as using a pool noodle, bolster, or a specific mattress. However, during multiple observations, it was noted that no such device or mattress was in place to define the bed borders as required by the care plan. Staff interviews confirmed that the intervention was not implemented. A CNA and the MDS Coordinator both verified that the resident's bed did not have any defined borders in place, despite the care plan directive. The Director of Nursing also acknowledged that the intervention should have been present. The resident had experienced multiple falls since admission, and at the time of observation, had visible bruising and steri strips on her right elbow, further indicating recent injury.