Failure to Provide Non-Skid Mat as Fall Prevention Intervention
Penalty
Summary
A deficiency was identified when a resident with dementia, psychosis, and osteoporosis, who required substantial assistance with transfers and was assessed as a fall risk, did not have a non-skid mat on her wheelchair as specified in her care plan. The care plan, dated 4/5/23, included an intervention to provide a non-skid mat under the wheelchair seat cushion to reduce the risk of falls, but during observation and record review, it was found that this intervention was not implemented. A Licensed Vocational Nurse confirmed during an interview and observation that the non-skid mat, which was available in the facility, was not present under the resident's wheelchair seat cushion as required. The facility's policy on fall precautions states that assistive devices and equipment should be used appropriately to maximize resident safety, but this was not followed in the resident's case.