Failure to Provide Ordered Enabler Bars Resulting in Two Bed Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered bilateral enabler bars were in place on a resident’s bed to prevent falls. The resident had multiple significant diagnoses, including COPD, lung cancer, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, depression, urinary incontinence, dysphagia, aphasia, dementia, chronic respiratory failure, and stage two chronic kidney disease, and was receiving hospice services. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 14, used a wheelchair, and required supervision or touching assistance for transfers. The resident’s ADL documentation from late August and late November indicated bilateral enablers to assist with turning and repositioning, and physician orders dated January showed bilateral enabler bars had been ordered since late August for this purpose. Despite these orders, the resident experienced two falls from bed after a room change. Progress notes documented that in December the nurse was called and found the resident on the floor near the bed, with the resident stating she was trying to get up from bed when she fell; neurological status and vital signs were assessed and the resident denied pain. A subsequent clarification indicated this fall was unwitnessed. In mid-January, another progress note recorded the resident lying on her right side on the floor next to the bed, stating she had slid; she denied attempting to get out of bed and denied hitting her head, and a bruise was noted on the left lower extremity. Neuro checks were within normal limits, and the resident was assisted back to a wheelchair while bed linens were changed. Record review showed that staff had been signing the medication and treatment administration records in December and January indicating that bilateral enabler bars were in place, even though no bars were actually on the bed. An anonymous complaint reported that the resident had fallen out of bed because she did not have assist bars, and that she had requested assist bars multiple times since mid-December. The resident confirmed during interview that she had not had enabler bars on her bed since moving to the new room until a half rail was installed the day before the surveyor’s observation, and she stated she preferred an enabler bar. The DON confirmed that when the resident’s room was changed in November, the resident did not take the prior bed, and when hospice delivered a new bed in December, it did not include enabler bars, leaving the resident without the ordered bilateral enabler bars despite ongoing documentation that they were in place and despite two falls from bed during this period.
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