Failure to Maintain Safe Bed Positioning for Residents at Fall Risk
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for residents at risk for falls, as evidenced by observations and interviews involving two residents. One resident, with a history of falling, a left pubis fracture, and recent joint replacement surgery, was observed in bed with the bed not locked, despite clear indicators and care plan interventions requiring the bed to be locked and in a low position. A therapy screen had previously identified this resident as a fall risk with safety concerns, and a yellow falling star was posted outside the room to indicate this risk. The LPN confirmed during the observation that the bed was not locked as required. Another resident, also with a history of falls and recent joint replacement, was found in bed with the bed left in the highest position, contrary to the care plan intervention to keep the bed in the lowest position. The resident, identified as a fall risk by a yellow falling star, reported that staff had been present to assist with therapy but left the bed elevated and unattended. The LPN confirmed that the bed should not have been left in the highest position. These failures demonstrate that the facility did not consistently implement fall prevention interventions as outlined in their policy and residents' care plans.