Failure to Provide Fall Mat as Ordered for High-Risk Resident
Penalty
Summary
A facility failed to ensure that a resident with a history of falls had a fall mat at the bedside as ordered by the physician. The resident was admitted and readmitted with diagnoses including lack of coordination, history of falling, and schizophrenia, and was documented as not having the capacity to make decisions. Physician orders and the resident's care plan both specified that the bed should be kept at the lowest position and a floor mat should be used to prevent injury. The resident's assessments indicated a high risk for falls, including a recent actual fall, and the resident was unable to stand, transfer, or walk independently. During an observation and interview, it was found that there was no floor mat present at the bedside, contrary to the physician's order and care plan. A CNA confirmed that the resident was supposed to have a floor mat due to a history of climbing out of bed and previous falls, and acknowledged that the absence of the mat could result in injury if the resident fell. The facility's policy required staff to implement interventions based on specific fall risks, but this was not followed in this case.