Failure to Maintain Bed in Low Position for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a fall prevention intervention for a resident identified as high risk for falls. The resident, who had diagnoses including Alzheimer's disease, muscle weakness, gait abnormalities, and pain, was assessed with a high fall risk score. The resident's care plan specifically required that the bed be kept in the low position as a safety measure. However, during an observation, the resident was found lying in a bed that was not in the low position, contrary to the care plan and facility policy. A family member expressed concern about the resident's risk of falling, noting that the resident attempted to get out of bed unassisted. A licensed nurse confirmed that the bed was not in the low position and subsequently lowered it. The Director of Nursing also acknowledged that the bed should have been kept low according to the resident's care plan. The facility's fall management policy required beds to be placed in the lowest position as a universal fall prevention measure, which was not followed in this instance.