Failure to Maintain Low Bed Position for High Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a high fall-risk resident’s environment was free from accident hazards and that care-planned fall-prevention interventions were implemented. The resident was admitted with diagnoses including left shoulder primary osteoarthritis, morbid obesity, and right knee pain, and had a history and physical noting fluctuating capacity to understand and make decisions. The resident’s care plan for fall risk, initiated shortly after admission, specified that the bed should be kept in a low position with brakes locked. A subsequent MDS assessment documented that the resident’s cognitive skills for daily decision-making were intact and that the resident required moderate assistance for toileting and lower body dressing. A Fall Risk Observation/Assessment identified the resident as being at high risk for falls. During an observation outside the resident’s room, surveyors found the resident asleep in bed with the bed in a high position, contrary to the care-planned intervention. In interviews and concurrent record reviews, the ADON confirmed there were no care plan interventions addressing the bed being in a high position and acknowledged that the resident could fall and be injured if the bed were high. CNA 1 reported it was the first time she observed the bed too high and stated the resident could fall off the bed if left in that position. The DON reviewed the Fall Risk Observation/Assessment and confirmed the resident was high risk for falls, that there was no care plan developed for use of a high bed position, and that the resident raised the bed and this preference had not been care planned. The facility’s Falls/Accident/Fall Management Prevention policy stated that, based on assessment, staff and the physician will identify pertinent interventions to prevent falls and address fall risks, but this was not followed in relation to the resident’s high bed position.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.