Failure to Maintain Bed in Low Position and Use Floor Mat Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was in the low position and that a floor mat was in place as required by the resident's care plan. The resident, who was dependent for care and required a mechanical lift for transfers, was found on the floor next to the bed with a laceration above the right eyebrow after attempting to reach for a drink. The bed was observed to be in a high position and the floor mat was missing at the time of the incident. Staff interviews confirmed that the resident was left in bed with the mechanical lift sling under him, and the required safety interventions were not in place. The resident's medical history included significant risk factors such as a history of CVA with right hemiplegia, COPD, atrial fibrillation, CHF, epilepsy, and other chronic conditions. The care plan specifically directed staff to keep the bed in the lowest position and to apply floor mats to the side of the bed. Despite these interventions being documented, they were not implemented, resulting in the resident sustaining an injury that required sutures and evaluation at the emergency room.