Failure to Implement Care-Planned Low Bed Intervention Resulting in Resident Fall and Rib Fractures
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall intervention for a resident identified as high risk for falls and bleeding. The resident’s care plan documented multiple diagnoses including severe Parkinson’s disease with dyskinesia, prior stroke with no use of the left arm, atrial fibrillation on anticoagulant therapy, dysphagia, protein-calorie malnutrition, and other chronic conditions. The care plan, initiated months before the incident, specified that the resident was non–weight bearing, totally dependent on staff for all ADLs, and at high risk for falls, with an intervention added for the bed to be kept in a low position and the resident to be positioned in the middle of the mattress. The resident was also identified as being at high risk for bleeding due to anticoagulant use, and the MDS documented that the resident was cognitively intact but totally dependent for functional status. On the night of the unwitnessed fall, the CNA assigned to the resident reported that she had seen the resident sleeping in bed around 1:00 a.m., then went to the nurse’s station to eat with other staff. Afterward, when she resumed rounding, she observed the resident’s feet on the ground from the doorway and found the resident on the floor next to the bed, lying on the left side and propped up on the right arm. The resident stated he had been hollering for help and that his chest hurt. The CNA and other staff, including two LPNs and another CNA, responded; the resident was assessed and returned to bed using a mechanical lift. Multiple staff, including the assigned CNA, another CNA, and an LPN, consistently described the bed as being at about waist height with side rails up at the time the resident was found on the floor. The assigned CNA stated she was new, was unaware the resident was a fall risk, and did not know the bed was supposed to be in a low position. Subsequent hospital records from the same date documented that the resident, who could not get out of bed or ambulate independently and was on a blood thinner, was found on the floor with an unknown time on the floor and complained of mid-sternal and right-sided rib pain. Imaging showed acute right 3rd through 6th rib fractures, with old rib fractures also noted, and the resident was admitted for pain control and monitoring for bleeding. During the surveyor’s observation, the resident confirmed that he had rolled out of bed, had been calling for help, and that his bed was usually higher than its current position, indicating it was normally at about the surveyor’s waist level. The DON confirmed that the care plan contained interventions for the bed to be in a low position and for the resident to be positioned in the middle of the mattress, and acknowledged that the bed should not have been in a high position while the resident was sleeping. Facility policies on incidents/accidents and fall prevention required safety interventions to be implemented and consistently maintained for residents at risk, and assigned nursing personnel were responsible for ensuring ongoing precautions were in place.
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