Failure to Maintain Fall Precautions and Supervision for At-Risk Resident
Penalty
Summary
A resident with a history of falls and moderate cognitive impairment was observed lying unattended in a high-positioned bed with only one floor mat in place, despite physician orders for bilateral floor mats and a care plan intervention requiring the bed to be kept in the lowest setting at all times. The resident was dependent on assistance for activities of daily living and had experienced a fall within the past several months. During the observation, no staff were present in the room, and the Certified Nursing Assistant (CNA) responsible for the resident was found gathering linens in the hallway. The CNA stated that while providing care, one floor mat was removed and the bed was raised for body mechanics, but the bed was left elevated and the resident unsupervised while the CNA left the room to get linens. Facility policy requires that interventions to reduce accident risks, such as keeping the bed low and ensuring supervision when safety equipment is removed, be implemented for residents at risk for falls. The failure to maintain the bed in the lowest position and to provide adequate supervision resulted in a deficiency related to accident hazards and resident safety.