Failure to Maintain Bed in Lowest Position for Fall-Risk Resident
Penalty
Summary
Facility staff failed to implement post-fall interventions for a resident identified as a fall risk. The resident, who had diagnoses including hemiplegia and hemiparesis following an intracranial hemorrhage, was assessed as having severe cognitive impairment and was dependent on staff for transfers. Despite a care plan intervention to keep the bed in the lowest position to prevent further falls, the resident's bed was repeatedly observed in the highest position during multiple observations and interviews. Staff present in the room did not lower the bed after providing care, and the bed remained in the highest position until the surveyor exited the room. Interviews with staff revealed inconsistent practices regarding bed positioning, with one CNA stating she left the bed in the highest position due to being rushed and suggesting that licensed staff may have raised it for other reasons. The Registered Nurse Supervisor confirmed that the intervention after the resident's fall was to keep the bed in the lowest position, and acknowledged that failure to do so could lead to another fall. The facility's policy required staff to monitor and document residents' responses to fall prevention interventions, but this was not followed in the case of this resident.