Failure to Place Fall Mat as Ordered for Resident with Fall History
Penalty
Summary
Staff failed to ensure that a fall mat, as ordered by the physician, was in place next to a resident's bed when the resident was in bed. The resident had a documented history of falls and a diagnosis of dementia, and after a previous fall, the care plan included placing a fall mat and keeping the bed in the lowest position when the resident was in bed. Despite these orders, observations on two separate occasions found the fall mat folded up next to the bathroom rather than positioned next to the bed while the resident was in bed with the bed in the lowest position and the head elevated. Interviews with the resident's family member, an LPN, and the DON confirmed that the fall mat was supposed to be next to the bed whenever the resident was in bed, in accordance with the physician's order and the resident's fall history. The staff's failure to follow these orders and ensure the fall mat was properly placed constituted a deficiency in providing adequate supervision and accident prevention for the resident.