Failure to Assess and Provide Bed Rails Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with significant mobility limitations and multiple comorbidities, including congestive heart failure, dementia, diabetes, and hypertension, was not adequately protected from accident hazards during care. The resident required substantial to maximal assistance for mobility and was identified as a fall risk upon admission. Despite repeated requests from both the resident and his daughter, who was his Power of Attorney, for bed rails to be installed, no bed rail assessment was documented, and bed rails were never provided. The facility's policies required assessment and informed consent for bed rail use, but these steps were not followed. The incident occurred when a CNA was providing incontinence care and rolled the resident onto his side on a bed that was elevated to waist level. The resident, who typically used a trapeze bar for self-adjustment but not for turning, was left at the edge of the bed and subsequently fell to the floor. The fall was unwitnessed by the resident's private aide, who was not permitted to assist with care. The resident sustained a right femoral neck fracture, a left scalp laceration, a hematoma of the frontal scalp, and multiple bruises and skin tears. The resident and his daughter both reported that requests for bed rails had been made multiple times, but these were not acted upon by facility staff. Interviews with facility staff revealed that the DON relied on nursing judgment rather than completing a documented bed rail assessment, and the care plan did not include specific interventions to address the resident's risk of falling from bed during care. The facility's fall management and bed rail policies were not followed, as risk factors were not fully evaluated, and care plan interventions were insufficient to prevent the accident. The resident's daughter was not promptly notified of the fall, learning about it from a private aide instead. The lack of appropriate assessment and implementation of assistive devices directly contributed to the resident's injuries.