Failure to Prevent Falls and Ensure Safe Bed Settings
Penalty
Summary
The facility failed to provide adequate protective oversight and prevent falls for a resident with multiple risk factors, including end stage renal disease, heart failure, muscle weakness, and a right above-the-knee amputation. The resident was assessed as a high fall risk, required extensive assistance with activities of daily living, and was dependent on staff for transfers and mobility. Despite these needs, staff did not consistently ensure that the resident's bed was kept in the lowest position while the resident was in bed, as required by the care plan and facility policy. Additionally, the resident's low air loss mattress was repeatedly set at a weight setting significantly higher than the resident's actual weight, contrary to manufacturer instructions and facility expectations. Observations confirmed that the mattress was set at 340 pounds while the resident weighed 268 pounds, which staff acknowledged could contribute to the resident rolling out of bed. The resident experienced multiple falls from bed, often while reaching for personal items or attempting to reposition, and reported discomfort from frequently sliding down in bed, with feet resting on the footboard. After several falls, there was no documentation that new fall risk interventions were implemented in a timely manner following each incident, as required by the facility's fall policy. Staff interviews revealed inconsistent practices regarding the use of mechanical lift slings, bed positioning, and mattress settings. The resident continued to experience falls, some resulting in skin tears, and staff failed to consistently apply or document new interventions after each event.