Failure to Ensure Fall Mat Placement for Resident at Risk of Falls
Penalty
Summary
A deficiency was identified when a resident with a history of falls, unsteadiness on her feet, and severe cognitive impairment was observed lying in bed without a fall mat placed alongside her bed, as required by her care plan. The resident's care plan, updated after a hip fracture from a previous fall, specifically included the intervention of having a floor mat alongside the bed to prevent further accidents. During the observation, the fall mat was found under the bed rather than in the correct position next to it. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that the resident was considered a fall risk and that both the low bed position and the placement of the fall mat alongside the bed were necessary interventions. Staff acknowledged that the fall mat should have been in place and that its absence was likely due to it not being repositioned after care activities. The facility's policy on fall management also requires maintaining an environment as free of accident hazards as possible and implementing appropriate interventions to prevent falls.