Failure to Maintain Low Bed Position for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident assessed as high risk for falls had their bed placed in the lowest position, as required by the resident's care plan under the Falling Star Program. The resident, who had diagnoses including generalized weakness, cognitive impairment, poor balance, decreased strength, and a history of falls, was observed asleep in bed positioned close to the edge of the mattress. Measurement of the bed height revealed it was set at 16 inches from the floor, rather than the lowest possible setting of 14 inches, as specified in the care plan. In contrast, the resident's roommate's bed was observed to be almost at floor level. Interviews with facility staff, including the Registered Nurse Supervisor and the Director of Nursing Services, confirmed that interventions such as low bed positioning are discussed and expected to be implemented according to residents' care plans to reduce fall risk. The facility's policies require that care plan interventions be implemented based on ongoing assessments and that specific fall prevention measures be carried out for residents at risk. Despite these policies and the resident's documented needs, the intervention to keep the bed in the lowest position was not followed at the time of observation.