Failure to Maintain Bed in Lowest Position for Resident on Fall Precautions
Penalty
Summary
A deficiency was identified when staff failed to ensure that a resident's bed was maintained in the lowest position as required by the care plan and physician orders for fall precautions. The resident, who had diagnoses including dementia, epilepsy, repeated falls, and muscle weakness, was admitted with a history that placed them at increased risk for falls. The care plan specifically directed that the bed be kept in the lowest position to mitigate this risk. Observations on two separate occasions found the resident's bed not in the lowest position while the resident was in bed. Certified Nursing Assistant 1 and a Licensed Vocational Nurse both acknowledged during interviews that the bed should have been lowered in accordance with fall precaution protocols. The Director of Nursing also confirmed that beds should be kept in the low position to reduce harm from falls. These findings were based on direct observation, record review, and staff interviews.