Failure to Maintain Bed in Low Position Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was maintained in the low position as required by the resident's care plan. The resident, who had a diagnosis of Alzheimer's dementia, a history of falls, severe cognitive impairment, and was dependent on staff for all activities of daily living, was identified as being at high risk for falls. The care plan and physician orders specified the use of bilateral bolster pillows, floor mats, and keeping the bed in the lowest position to minimize injury risk. Despite these interventions, the bed was found elevated at the time of the incident. On the day of the event, a family member visiting the resident observed that the bed was elevated and subsequently found the resident on the floor, in pain, and with visible injuries. Multiple staff members, including CNAs and LVNs, confirmed that the bed was elevated to hip height when they responded to the incident. The resident sustained fractures to the left lower leg, as confirmed by hospital records, and required transfer to an acute care hospital for treatment. Facility documentation, interviews, and medical record reviews all indicated that the required fall prevention interventions were not fully implemented, specifically the failure to keep the bed in the low position. The facility's own policies and procedures mandated that residents at risk for falls have appropriate interventions in place, including maintaining the bed in the lowest position, but this was not adhered to at the time of the incident.