F0689

G

Failure to Follow Care Plan and Maintain Safe Bed Position Leads to Resident Fall and Head Laceration

Carlisle, Pennsylvania Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The facility failed to implement required safety interventions and supervision for a dependent resident, resulting in a fall with a scalp laceration. The resident had diagnoses including hemiplegia, hypertension, dementia, history of CVA, muscle weakness, abnormal posture, and spinal malformation, and was care planned as totally dependent for bed mobility and transfers, requiring a Hoyer lift with two-person assist and a regular scoop mattress with extensive assist of two. The care plan also identified the resident as at risk for falls, with an intervention to maintain the bed in a low position, and a task directing staff to place a body pillow on the right side at all times when the resident was in bed. Documentation on the day of the incident showed that the body pillow was not in place on the right side of the bed at 11:08 AM. The resident’s MDS and clinical record consistently documented that the resident did not roll, lean, or move in bed without maximal assistance and was dependent on staff for all bed mobility.

Later that day, an unwitnessed fall occurred, and the resident was found prone on the floor between the bed and the outer wall with a frontal scalp laceration measuring approximately 4.0 cm by 4.0 cm by 0.1 cm, requiring 8 sutures in the ED. The incident report and staff statements confirmed that the resident required a mechanical lift with two-person assist, did not move in bed independently, and had no bed movement per nurse aides. Staff statements indicated that shortly before the fall the resident had been seen lying in the middle of the bed, with the bed at waist level, and a clean brief unfolded on the bed, suggesting care was being or had been provided; one aide reported seeing the resident “flip over” on the floor and trying unsuccessfully to pull her back, and another reported the bed was at waist level and the resident was wearing no brief. A nurse aide interview revealed that at the time of the fall the bed was in a tilted position, the resident was leaning off the bed, and there was no body pillow on the right side. The Nursing Home Administrator acknowledged that the bed was tilted up and that staff attempted to grab the resident but could not explain how the resident, who was documented as unable to move in bed without assistance, came to be leaning off the side of the bed. These findings support that the facility did not follow care-planned interventions, including maintaining the bed in low position and ensuring use of the body pillow, and did not provide adequate supervision to prevent the accident.