Failure to Replace Damaged Bedside Fall Mat
Penalty
Summary
The facility failed to maintain a sanitary environment by not replacing a cracked and split bedside fall mat for a resident with a history of falls, abnormal posture, and lack of coordination. The resident's care plan identified a risk for falls and included the use of fall mats as an intervention. During multiple observations, the fall mat at the resident's bedside was found to be cracked and split along its entire length, exposing the interior layer of the mat. Interviews with facility staff confirmed that the mat was in disrepair and could not be properly cleaned. The Director of Maintenance stated that nursing staff were responsible for replacing damaged fall mats, but no replacement had been obtained from central supply, nor had a service request been entered into the maintenance system. The unit manager acknowledged the mat's poor condition and confirmed it was an older version that had not been replaced.