Failure to Maintain Low Bed and Supervision Leads to Fall With Injury
Penalty
Summary
Failure to maintain a resident’s bed in the lowest position and to provide adequate supervision resulted in a fall with injury. The facility’s fall policy requires assessment of fall risk and individualized, person-centered care planning, with all staff having access to the care plan and Kardex to ensure consistent implementation of fall prevention strategies. The resident involved had unspecified dementia with agitation and required substantial/maximal assistance for bed mobility. A fall risk assessment identified the resident as high risk for falls, and the care plan documented that the bed was to be maintained in the lowest position due to unsteady gait, poor balance, and generalized weakness. Despite this, on the day of the incident the CNA raised the bed from its lowest position while preparing the resident for the day. According to staff interviews and the incident report, the CNA assisted the resident to a sitting position on the edge of the bed, then laid the resident back down and turned away to retrieve clothing or a mechanical lift device while the bed remained elevated approximately two feet from the floor. During this time, the resident slid off the bed, landing on her buttocks and then falling forward, striking her head on the floor. The LPN who responded confirmed that the bed was not in the low position when she entered the room and noted that the resident was known to attempt to scoot off the bed and could be combative during transfers. The DON acknowledged that if the care plan required a low bed, the CNA should have maintained the bed in the lowest position and should not have turned away from the resident while the bed was not in a low position. The resident was treated in the emergency room for soft tissue swelling around the left eye and a 2-centimeter laceration above the left eyebrow, which was closed with adhesive glue.
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