Failure to Maintain Low Bed Position for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and implement fall-prevention interventions as care planned for a resident with significant physical and cognitive impairments. The resident had diagnoses including right above-knee amputation, right hemiplegia and hemiparesis following cerebral infarction, cognitive communication deficit, difficulty walking, and right-hand contracture. The resident sustained an unwitnessed fall from bed with head involvement, resulting in a hematoma to the right forehead and right eye, and was sent to the emergency room for evaluation. Subsequent assessments, including a Morse Fall Scale, identified the resident as high risk for falls, and the care plan was updated to direct staff to keep the bed in the lowest position due to the prior fall and the resident’s right AKA. Despite this care plan directive, multiple observations over two days showed the resident lying in bed with the bed elevated rather than in the lowest position. A CNA entered and exited the resident’s room without lowering the bed, and follow-up observations later that day and the next morning confirmed the bed remained elevated. During interviews, an RN acknowledged that the bed was not in the lowest position despite the resident’s fall risk and stated it should be as low as the mechanical bed would allow. The CNA reported that she only learned that day that the resident was a fall risk and that fall interventions were outlined in the care plan, including keeping the bed in the lowest position. Another LPN confirmed that the resident was at risk for falls and that the bed should be in the lowest position, and also stated that staff do not document bed position each shift.
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.