Failure to Timely Remove Unbeneficial Fall Interventions and Ensure Proper Mattress Fit
Penalty
Summary
Facility staff failed to remove fall interventions in a timely manner when they were assessed as unbeneficial for a resident with multiple complex medical diagnoses, including cancer, heart failure, kidney disease, muscle weakness, and Parkinson's disease. Despite documentation that floor mats were not an appropriate intervention and should be discontinued, observations showed that the mats remained at both sides of the resident's bed several days after the decision. The DON confirmed that staff did not implement the change as expected, resulting in the continued presence of the floor mats. Additionally, the facility did not ensure that a resident's mattress fit the bedframe properly. A resident with a progressive neurological disorder, wasting condition, and a history of falls was observed lying on a low air loss mattress that extended beyond the bedframe by one to four inches. Staff confirmed that the mattress overhang required correction and that extender bars were needed to secure the mattress for safety, as the mattress should be properly fitted to the bedframe.