Failure to Ensure Proper Placement of Fall Mats for High-Risk Resident
Penalty
Summary
The facility failed to ensure that floor mats, intended to prevent injury from falls, were properly placed at the bedside for one resident with significant fall risk. The resident in question had diagnoses of epilepsy and dementia, with severely impaired cognition and physical limitations affecting both upper and lower extremities. According to the resident's physician order and care plan, floor mats were to be placed at the bedside and checked every shift due to behaviors such as rolling out of bed or placing herself on the floor. However, during multiple observations, only one mat was found at the bedside while the other was under the bed and not accessible for fall protection. Interviews with nursing staff confirmed that the floor mats were not positioned as required by the physician's order and care plan. The staff acknowledged that the improper placement of the mats would not prevent injury if the resident were to fall. The facility's policy on fall prevention required individualized care planning and implementation of interventions based on identified risk factors, but these were not followed in this instance, resulting in a deficiency related to accident hazard prevention and supervision.