Citation Number: 230004705
Citation Date: 2/27/2008
Violation Date: 5/21/2007
Class: AA
Penalty: $ 100000.0

An 84 year old female was admitted to the facility on 10/25/05 and was totally dependent on staff for all activities of daily living. The resident's careplan called for the use of half bed rails (rails positioned at the top of the bed, so a person can get out of the lower half of the bed) for positioning and mobility, and alarms while she was in bed. On 5/21/07 at 4:15 am, the resident was found dead, laying on the floor of her room with her head caught between the half rail and the bed. On 6/20/07, an administrative nurse stated the bed alarm was not used because the resident "never tried to climb out of bed since her admission." However, a CNA who provided care to the resident for eight years stated the resident "was known to roll out of bed." The facility was cited for failing to ensure the resident was safe from accidents by not using a bed alarm to alert staff the resident was getting out of bed and for failing to take away the residents side rails when she was not being turned.