Failure to Implement Fall Risk Precautions and Maintain Safe Environment
Penalty
Summary
The facility failed to implement appropriate fall risk precautions for multiple residents identified as being at risk for falls. One resident was observed with a mattress that was significantly larger than the bed frame, causing the mattress to hang off and angle downward. This resident reported ongoing issues with the mattress, including slipping while trying to get out of bed, and stated that complaints about the mattress had been made for months. Both nursing and maintenance staff confirmed that the mattress did not fit the bed frame and acknowledged the risk of falls associated with this improper fit. The resident's care plan documented a risk for falls due to multiple medical conditions, and facility policy required that malfunctioning equipment be reported or removed from service immediately. Another resident, who was severely cognitively impaired and at high risk for falls, was observed in bed without the required floor mat in place. The floor mat, intended to minimize injury in the event of a fall, was found either under the bed or standing against the wall during multiple observations. Staff interviews confirmed that the floor mat should have been positioned at the bedside whenever the resident was in bed, as specified in the resident's care plan and the facility's fall prevention guidelines. The lack of proper placement of the floor mat represented a failure to follow the prescribed fall prevention interventions. Additional deficiencies were noted for other residents at risk for falls, including beds left in a high position after care was provided. Several residents, who were dependent on staff for activities of daily living and unable to adjust their own beds, were found with their beds elevated, contrary to their care plans and facility policy. Staff acknowledged that beds should have been returned to a low and safe position after care to reduce the risk of injury from falls. One resident was also found to lack a care plan with fall prevention interventions despite being assessed as at risk for falls.