Failure to Secure Bed Rails Results in Resident Fall
Penalty
Summary
A resident with quadriplegia, contractures, and a history of traumatic brain injury, who was completely dependent on staff for all activities of daily living and nonverbal, experienced a fall from bed. The incident occurred when a CNA was changing the resident's diaper and turned the resident onto his right side. The CNA then moved to the opposite side of the bed, leaving at least one bed/safety rail down, the bed unlocked, and the room poorly lit. As a result, the resident fell from the bed while the CNA was on the other side. Facility records and staff interviews confirmed that the side rail on the side closest to the window, where the resident fell, was lowered at the time of the incident. The facility's fall prevention policy required that side rails be kept in the raised position when a resident is in bed. The DON confirmed that the fall was avoidable and that the CNA did not ensure the safety rails were secure and in place before leaving the resident's side, directly leading to the accident.