Failure to Maintain Bed in Lowest Position and Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
Nursing staff failed to ensure that a resident with severe cognitive impairment and a history of falls received adequate supervision and assistive devices to prevent accidents. The resident, diagnosed with neurocognitive disorder with Lewy bodies, psychotic disorder, generalized anxiety disorder, and severe dementia with behavioral disturbances, was observed lying in bed with the head elevated and the bed positioned approximately 3.5 feet off the floor. The care plan for this resident required the bed to be kept in the lowest position with brakes locked and frequent observation, as well as placement in a supervised area when out of bed. However, during observation, the resident was left unsupervised, moving and reaching for blankets on the floor, with no staff in the immediate vicinity. A CNA later confirmed that she had transferred the resident to bed 15-20 minutes prior and admitted to forgetting to lower the bed to its lowest position, despite knowing the resident was a fall risk and had a history of attempting to get out of bed without assistance. The DON also acknowledged that the resident was impulsive, unsteady, and required the bed to be in the lowest position to prevent falls. Facility policy on fall risk management specifically identified incorrect bed height as an environmental risk factor for falls. No falls were recorded for the resident during the review period, but the failure to follow care plan interventions and provide adequate supervision constituted a deficiency.