Briarwood Village

During an interview on [DATE] at 12:30 P.M., the DON confirmed the air mattress that was applied to Resident #01's bed provided little to no perimeter resistance when pressure was applied to the mattress edge.

Additional interview verified no documentation contained in the medical record indicated Resident #01's air mattress or bed were assessed for appropriate use.

During an interview on [DATE] at 1:05 P.M. via telephone, Hospice Physician #2 revealed the primary cause of Resident #01's death was due to cervical fractures sustained from the fall from bed on [DATE].

During an interview on [DATE] at 11:06 A.M. via telephone, CNA #89 confirmed Resident #01's bed was elevated approximately three feet when Resident #01 fell from the bed on [DATE].

CNA #89 walked around the foot of the bed to the left side of the bed and proceeded to access a trash can located at the left side of the bed. CNA #89 confirmed she took her visual focus away from Resident #01 while tending to the trash receptacle which left the resident unattended while in a elevated bed. CNA #89 responded to Resident #01 yelling out and observed the resident rolling from bed. CNA #89 lunged towards Resident #01.

However, the resident proceeded to fall to the floor and sustained an injury to the head. CNA #89 confirmed she received training related to the transfer and use of mechanical lifts.

However, no training included maintaining supervision to prevent accidents.

Review of the policy titled Fall Reduction Policy, approved [DATE], revealed based on the outcome of fall assessments, a fall risk reduction plan will be incorporated into the resident's plan of care.

The interdisciplinary team will review the residents' fall risk reduction plan at a quarterly minimum, during care conference and modify the plan as needed, based on the resident's functional status during the review period.

Referrals will be made to other health professionals as needed.

Follow-up investigations will be carried out to ascertain the cause of the incident to reduce the risk of further occurrences.

Employee education will include body mechanics, transfer/ambulation techniques, transfer/ambulation equipment and assistive devices, maintenance of equipment and assistive devices.

Review of the manual titled Joerns User-Service Manual dated 2023, documented important precautions included the following: Keep bed in lowest position except when providing care.

Bed should be at lowest convenient height for entry or exit.

Failure to do so could result in injury.

Use of an improperly fitted mattress could result in injury or death. An optimal bed system assessment should be conducted on each resident by qualified clinician or medical provider to ensure maximum safety of the resident.

This deficiency represents non-compliance investigated under Complaint Number 2565060.

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