Failure to Develop and Implement Care Plan for Fall Prevention Related to Bed Height
Penalty
Summary
The facility failed to develop and implement a care plan addressing a resident's preference for raising his bed to its maximum height, despite the resident being at high risk for falls. The resident had multiple diagnoses, including lack of coordination, unsteadiness, idiopathic aseptic necrosis of the femur, wrist drop, spinal cord compression, cervical spinal stenosis, COPD, and sciatica. The care plan in place identified fall risk factors such as poor balance, unsteady gait, decreased functional status, and attempts to stand unassisted, and included interventions like joint mobility assessments, ensuring the call light was within reach, and monitoring for sedation and balance issues. However, it did not address the specific issue of the resident raising his bed to the highest position, which was observed multiple times during the review period. Nursing progress notes and direct observations confirmed that the resident frequently kept his bed in the highest position and was unable to reach his call light, further increasing his fall risk. Staff interviews revealed that the resident was non-compliant with keeping the bed in a low position for safety, and the DON acknowledged that no care plan had been developed to address this behavior. The facility's policy required ongoing assessment and revision of care plans as residents' conditions changed, but this was not followed in the case of this resident's bed height preference and associated non-compliance.