Failure to Maintain Safe Bed Environment Results in Resident Fall
Penalty
Summary
A resident with a history of epilepsy, repeated falls, and left-sided hemiplegia was identified as being at risk for injuries from falls, with care plan interventions including ensuring the call light was within reach and providing supervision as indicated. The resident's MDS indicated intact cognition but significant physical impairment, requiring assistance with mobility and transfers. Despite these interventions, the resident was found on the floor after sliding out of bed. At the time of the fall, a new alternating pressure pad was in use, but there was no fitted sheet on the bed, only a flat sheet covering the mattress topper. The resident reported discomfort and sliding down the bed, and documentation confirmed the absence of a fitted sheet at the time of the incident. Staff interviews confirmed that all residents should have full linens, including fitted sheets, and that interventions for fall risk include low beds, fall mats, and frequent checks. The DON acknowledged that the resident had a low air-loss mattress and slid down the side of the bed due to the lack of a fitted sheet. The facility's policy requires the resident environment to remain as free of accident hazards as possible, but the omission of a fitted sheet contributed to the resident's fall.