Failure to Implement Fall Prevention Care Plan
Penalty
Summary
A deficiency was identified when a resident with a history of falls and moderate cognitive impairment was found lying unattended in a high-positioned bed with only one floor mat in place and no staff present in the room. The resident was dependent on assistance for activities of daily living and had previously experienced a fall. Facility policy and the resident's care plan required the bed to be kept in the lowest position at all times when the resident was unsupervised, and for bilateral floor mats to be used as a fall prevention measure. During the incident, a Certified Nursing Assistant (CNA) raised the bed and removed one floor mat while providing care, then left the resident unsupervised in the high bed while retrieving linens from the hallway. The CNA stated that the bed was left elevated for proper body mechanics and that the resident was sleeping at the time. The facility's risk manager confirmed that the expectation was for the bed to remain low and the resident to be supervised if a floor mat was removed. This failure to implement the fall prevention interventions outlined in the care plan constituted the deficiency.