Failure to Ensure Fall Mat in Place for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a fall mat, identified as a necessary intervention, was in place for a resident with significant risk factors. The resident had diagnoses including dementia, chronic obstructive pulmonary disease, polyneuropathy, generalized anxiety disorder, and major depressive disorder. Clinical assessments documented highly impaired vision, severe cognitive impairment, and a need for assistance with activities of daily living. After a fall incident in which the resident was found on the floor with an abrasion to the forehead, the interdisciplinary team determined that a fall mat should be placed at the bedside to reduce the risk of injury from future falls. Despite this intervention being documented in the care plan, multiple observations over several days showed that the fall mat was not present at the resident's bedside while the resident was in bed. During an interview, the Director of Health Services acknowledged that the fall mat was in the room but had been moved behind a chair, possibly by housekeeping staff after cleaning, and was not returned to its proper place. This lapse in ensuring the fall mat was in position constituted a failure to provide adequate supervision and accident hazard prevention as required.