Failure to Remove Damaged Fall Mat Creates Infection Control Deficiency
Penalty
Summary
A resident with quadriplegia, legal blindness, and aphasia was admitted to the facility and identified as being at risk for falls, with a fall mat care plan in place. During an observation, a blue fall mat next to the resident's bed was found to be ripped apart approximately three-quarters of the way, exposing the internal sponge-like material. This condition was noted in the presence of the resident and their representatives. The resident's clinical records indicated severely impaired decision-making abilities. Staff, including a Registered Nurse and the Infection Preventionist, confirmed that the torn mat could not be properly cleaned and posed an infection control concern, as it could harbor potentially infectious organisms. The facility's policies required removal of products with compromised integrity and identified proper cleaning, disinfection, and disposal of equipment as essential to infection prevention. The presence of the damaged fall mat in the resident's environment demonstrated a failure to implement effective infection control measures as outlined in facility policy.