Failure to Provide Fall Prevention Floor Mats for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide a high fall-risk resident with floor mats as indicated in the resident's care plan. The resident had a history of Guillain-Barre syndrome, osteoporosis with a pathological fracture, cognitive impairment, and a recent fall resulting in hospitalization for a fracture. The resident was assessed as being at high risk for falls, with care plans specifically stating that floor mats should be in place to help prevent injury from falls. Despite these documented interventions, observations revealed that no floor mats were present at the bedside, and staff interviews confirmed that the mats had not been implemented due to the absence of a physician's order. The care plan interventions, including the use of floor mats, were developed based on the resident's assessment, fall history, and medication profile. Staff acknowledged that the care plan required floor mats and that an order should have been obtained, but this step was missed, resulting in the intervention not being carried out. Facility policies also required the use of floor mats for residents at severely high risk for falls, but these were not followed for this resident, placing the individual at increased risk for injury from another fall.