F0600

G

Neglect Related to Failure to Maintain Bed in Low Position for High Fall-Risk Resident

New Iberia, Louisiana Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect by not ensuring the resident’s bed was maintained in the lowest position as required by the care plan and fall prevention policies. The resident had a documented history of high fall risk, including a fall risk assessment score of 17 in November 2025 and 19 in March 2026, and was on the facility’s Falling Star Program per physician orders. The resident’s care plan, initiated in September 2021, specifically directed staff to keep the bed in the lowest position with wheels locked to prevent falls and fall-related injuries. The facility’s Fall Prevention Program policy also required identification of high-risk residents and elimination of environmental hazards, including appropriate bed height.

On the morning of 03/13/2026 at approximately 6:50 a.m., a CNA assigned to the resident’s care conducted quick rounds on the hall where the resident resided. As she walked down the hallway, she observed that the resident’s door was open and saw from the hallway that the resident’s bed was not in its lowest position. Despite recognizing that the bed was elevated and acknowledging that she knew the bed should have been in the lowest position for this resident, the CNA did not enter the room, did not lower the bed, and did not notify the nurse or other staff about the unsafe bed height. She continued walking toward the dining room to perform breakfast meal service duties, assuming that other staff would get the resident out of bed.

At approximately 6:59 a.m., about nine minutes after the CNA observed the bed in a raised position and failed to intervene, a visitor walking down the hall heard the resident yelling. The visitor looked into the room and saw the resident lying on the floor near the bed and alerted housekeeping staff, who then notified the LPN and DON. Staff observed the resident on the floor, yelling out and complaining of left hip and leg pain, with bruising noted to the left temple and left leg shortening. Emergency medical services were contacted, and the resident was transported to the emergency room. Hospital x-rays taken that morning revealed a left femoral intertrochanteric fracture with displacement and surrounding soft tissue swelling, and the resident subsequently underwent surgery with intramedullary nailing of the left femur on 03/16/2026. The facility’s investigation, including review of video footage and staff interviews, confirmed that the CNA had identified the elevated bed and did not act, constituting neglect as defined in the facility’s Abuse/Neglect policy.