Failure to Implement Timely Bed Rail Safety Measures Results in Resident Injury
Penalty
Summary
The facility failed to ensure that staff updated and implemented proper safety measures, specifically regarding the use of bed rails, which resulted in a preventable fall and significant injury to a resident. The resident, who had a history of dementia, left hip fracture, and previous falls, was readmitted to the facility and experienced a decline in mobility after a fall while ambulating. Physical therapy evaluated the resident and recommended the use of side rails to assist with bed mobility and transfers, with the plan of care signed by a physician. However, the care plan was not updated to reflect the need for side rails, and there was a delay of approximately 20 days before the side rails were installed on the resident's bed. On the day of the incident, the resident fell out of bed and was found on the floor by a nursing assistant, complaining of back and leg pain. Progress notes indicated ongoing pain and a lack of effective pain management, with a delay in obtaining an X-ray to assess the extent of the injury. The X-ray, when finally completed, revealed a left femoral neck fracture and pelvic fracture, requiring the resident to be sent to the emergency department and subsequently undergo surgery. The resident, who had previously been ambulatory with a walker, now required a wheelchair and assistance from two staff members for mobility. Interviews with staff confirmed that the resident did not have side rails in place at the time of the fall, despite the physical therapy recommendation and physician's order. The Director of Nursing and other staff acknowledged the absence of side rails and the delay in their installation. The failure to update the care plan and implement the recommended safety measures directly contributed to the resident's fall, resulting in significant injury and a marked decline in functional status.