Failure to Maintain Bed in Lowest Position Leads to Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident's bed was returned to the lowest position prior to leaving the room, as required by the resident's care plan and facility policy. The resident had a history of falls, cerebellar ataxia, and some memory recall deficits, and was dependent on staff for activities of daily living. The care plan and nurse aide care card specifically directed that the bed be kept in the lowest position, with additional interventions such as floor mats and body pillows. On the day of the incident, a nurse aide raised the bed to waist height to feed the resident and did not return it to the lowest position before leaving the room, despite being aware of the care card instructions. As a result, the resident was found on the floor next to the bed with a bump on the head and was subsequently diagnosed with fractures of the C6 and C7 spine and a hematoma to the forehead. Interviews with nursing staff confirmed that the bed was not in the lowest position at the time of the fall, contrary to established protocols. Facility documentation and interviews indicated that the failure to follow the care plan and policy directly contributed to the resident's fall and resulting injuries.