Failure to Ensure Fall Mat in Place for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that the environment remained free from accident hazards and that a resident received adequate supervision and assistive devices to prevent accidents. Specifically, a resident with a history of unsteadiness, falls, dementia, and seizure disorder was observed lying in bed without the required fall mat in place; instead, the mat was folded and leaned against the wall. Physician's orders and the resident's care plan both specified that the bed should be kept in the lowest position with a floor mat at bedside as a fall prevention intervention. Multiple staff interviews confirmed that the fall mat was intended to be in place whenever the resident was in bed to help prevent injury in the event of a fall. The DON, CNA, and Administrator all stated the importance of the fall mat being positioned next to the bed while the resident was present. However, the facility did not provide a policy for fall mats prior to exit, and there was uncertainty among staff regarding when the mat should be used, contributing to the failure to implement the prescribed intervention.