Failure to Maintain Bed in Low Position Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was maintained in the lowest, most appropriate position as required by the resident's care plan and the facility's fall prevention policy. The resident had a documented history of falls, skin tears, and bruises, and the care plan specifically included an intervention for the bed to be kept in a low position when the resident was resting. On the night of the incident, the resident was found on the floor next to the bed with a large laceration on the right forearm, a hematoma on the forehead, and subsequently diagnosed with a spinal fracture. Both the Certified Nurse's Assistant and the LPN who responded confirmed that the bed was in a high position, contrary to protocol and the care plan intervention. The incident report and interviews with staff indicated that the bed was at the hip or waist level of the staff members, which was higher than required. The Director of Nursing confirmed that the low bed intervention had been in place since the resident's admission to reduce injury risk. The resident's Nurse Practitioner stated that the injuries sustained were a result of the fall and that the severity of the injuries would likely have been less if the bed had been in the correct low position. The failure to follow the care plan intervention directly led to the resident's injuries and the need for emergency medical treatment.