Resident Left Unattended in Raised Bed Despite High Fall Risk
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including epilepsy, chronic moderate intellectual disability, chronic kidney disease, bilateral cataracts, anxiety disorder, and hypertension, was left unattended in bed with the bed raised to a high position. The resident's records indicated severe cognitive impairment, a high risk for falls, and a need for assistance with all activities of daily living. The care plan specifically identified a risk for falls and a history of previous falls, with a goal to prevent fall-related injuries. On the day of the incident, a CNA exited the resident's room, leaving the bed in a high position and the resident unattended. Both the CNA and an LPN confirmed that the resident was at risk for falls and that the bed should have been left in the lowest position when unattended. The Director of Nursing also confirmed the expectation that the bed remain in the lowest position when staff are not present. This failure to follow established fall prevention protocols resulted in a deficiency related to accident hazards and inadequate supervision.